Energetic Allergy Healing Questionnaire

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I'm looking forward to working with you on addressing not only your physical symptoms but also the underlying emotional, mental, and spiritual factors attached to them. And assisting you into greater alignment and harmony with your environment, promoting overall well-being and personal growth.

This information allows me to work with a holistic view & approach. Please be as detailed & specific as possible

Name:
*

Email:

Phone Number (including area code)
*

Which Energetic Allergy Healing package are you interested in?
*

Energetic Allergy Healing Single Session

Energetic Allergy Healing 6 Week Package

How did you hear about me?

Date of Birth:
*

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Where do you live: City, State, Country?
*

What is your primary time zone? (I am CST/USA)
*

What outcome(s) are you desiring from booking the healing session(s)?
*

Do you have a serious known allergy that could be life threatening?
*

What is your present condition(s) and what you are experiencing?
*

How long have you been experiencing this?
*

Please list all medications, prescriptions, supplements you are taking, how long you have been taking them and why you are taking them. Include all antibiotics you have had in the past. (As best as you can.)
*

Please list any vaccines you have gotten within the last 5 years. Include the dates (approximate)
*

Have you had any dental work (root canals, implants, fillings, etc.) done in the past 2 years? If Yes, list below:
*

List your typical diet including meals and snacks, common foods and beverages. (Please include coffee, tea, alcohol - quantity consumed and how often) :
*

Are you allergic to any known foods? If yes, please list them.
*

List any non-food allergies: *

Do you smoke, ever smoked? Vape? Recreational drugs? If so, what and how often?
*

What foods and/or beverages do you crave?
*

Please list all serious illnesses/accidents you have experienced in the past, when you experienced them, the duration and what you experienced. How are they currently affecting you?
*

Please list all physical diagnosed conditions, past surgeries, along with dates (approximate). Describe any symptoms you still experiencing, chronic and acute as a result
*

Please list any mental and/or emotional diagnosis, along with dates (approximate). Describe any symptoms you still experiencing, chronic and acute as a result.
*

Are there any other significant events that have impacted your past health history that haven't been addressed above? How are they affecting you currently?
*

List all pets living with you (inside or outside your residence):
*

List hobbies/recreation (example: if you are an artist, do you work with oil or acrylic paints? Or do you hike, mountain bike, swim, etc)
*

Is there anything out of the ordinary that you are in contact with on a regular basis due to your work, place you live or hobbies?
*

If there is anything else that you would like to share with me, please elaborate :

Thank you for filling out this questionnaire. I will be in touch via the email address you provided within 72 hours to let you know whether I feel we are energetically aligned to work together.

If you haven't seen an email within 72 hours, be sure to check your spam folder. If you don't see it there, please email me at: laurie@lovelearnlaughwithlaurie.com

Remember to press the "Submit" button at the bottom.

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