Health and Vitality Program Intake Form

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Your Information - Step 1 of 2

make conditions significant

Name

First

Last

Phone

Age

What is your current health situation?

What specific health challenges or conditions would you like to focus on?

Do you feel there are emotional or energetic blockages contributing to your health challenges?

Have you experienced any significant life events that you feel may be affecting your health (e.g., trauma, major stress, etc.)?

What lifestyle changes or improvements would you like to make in your health and well-being?

Is there anything else you’d like to share that could assist in your health realignment?

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