Awareness Heals Discovery Questionnaire
As you reveal the emotional aspect of your life story, you become your own healer. Healing your life deserves your commitment and attention. It is both your responsibility and your gift to yourself.

If you are willing, I am willing to support you.

Once I have received your questionnaire and had a chance to review it, we can set a time for a 20-minute discovery session.

To your health and healing,


Nelie Johnson MD (Retired)

Email address *
What is your primary health concern? example: disease, emotion, condition, event (such as - losing job, losing a relationship, death in the family)
Your answer
What concerns you the most about it your primary health concern?
Your answer
When did you first notice the condition and also when did it become a real problem for you? (It may be the same date for both. month/year)
Your answer
On a scale of 1 to 10 (10 being the most troublesome), rate how much this issue interferes or affects your functioning in your life now?
Give 2 or 3 examples of how it interferes.
Your answer
What treatment, if any, have you had and are you taking for this condition or problem? - (example: counselling, medication, surgery) - and for how long?
Your answer
What results are you getting?
What improvements would you most like to see in your health?
Your answer
Are you ready to take ’response ability’ as being able to contribute to your own healing?
Are you willing to do whatever you can to help yourself regain health?
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