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Experience Healing with
Indigenous Healing Studio
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Vortex Energy Healing Form
Full Name
*
Date of Birth
Month
Month
Day
Year
Do you presently or have you ever suffered from any of the following?
*
Heart problems
High blood pressure
High cholesterol
Stroke
Lung issues
Cancer
Diabetes
Current broken bones/fractures
Arthritis
HIV/AIDS
Kidney problems
Repeated infections
Thyroid problems
Skin disease or sensitivity
Depression
Epilepsy/Seizures
Allergies:
Do you smoke?
*
Yes
No
Do you drink?
*
Yes
No
Do you have a pacemaker?
*
Yes
No
Do you suffer from insomnia (disturbed sleep)?
*
Yes
No
Do you suffer from chronic migraines?
*
Yes
No
Do you have significant stress in your life?
*
Yes
No
(For women) Are you pregnant?
Yes
No
I would like to add sage, cedar, Palo Santo, or spirit tobacco with an extra cost of $15
*
Yes
No
I prefer working with essential oils with an extra cost of $5
*
Yes
No
Please share any health or well-being concerns.
Signature
*
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Date
*
Month
Month
Day
Year
Submit
I am not medically licensed or certified and will not prescribe medications or give diagnosis. I advise you to consult with a doctor, if you are undergoing treatments or have a medical emergency.
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