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Getting to know you

Please fill out the following form
so we may better tailor our services and products to your needs.

First Name

Last Name

Gender

Date of Birth

Marital Status

No of children

Phone

Blood Type

Email

Address

Race

Religion

Company

Occupation

PLEASE COMPLETE THE BELOW IF CUSTOMER IS UNDER THE AGE OF 18.

Emergency Contact Person

Emergency Contact's Phone Number

Emergency Contact's Relationship

Initials

1) Are you pregnant?

No

Yes

2) Have you had received any form of medical treatments/surgeries or been hospitalised in the last 12 months?

No

Yes

If you answered yes to any question, please elaborate

3) Do you have any skin conditions/ allergies? (eczema etc)

No

Yes

4) Do you have any condition such as epilepsy or “fainting”?

No

Yes

If you answered yes to any question, please elaborate

Have you had received any form of medical treatments/surgeries or been hospitalised in the last 12 months?

No

Yes

Let us know you: health concerns:

Cardiovascular health, i.e. hypertension

Gastrointestinal health,,i.e. gastric reflux,

Pancreatic health, i.e. diabetes

Respiratory health, i.e. asthma

Kidney health, i.e. nocturia, inflammation

Bone health, i.e. osteoporosis, arthritis

Emotional stress: worry, fear, frustration, anger, impatience, trauma, irritability, lost of confidence

Hormonal/Stress, i.e. chronic fatigue

Thyroid health, i.e. hyper/hypothyroid

Sleep health, i.e. insomnia

mmune health,i.e. allergy

Male health, i.e. prostate

Female health, i.e. ovary, uterus

Eye health, i.e. cataract

Nutritional health

Relationship Stress: family, work

Anymore details you would like us to know?

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I declare that the info I’ve provided is accurate & complete

• Career wellbeing: about how you occupy your time or simply liking what you do every day
• Social wellbeing: about having strong relationships and love in your life
• Financial wellbeing: about effectively managing your economic life
• Physical wellbeing: about having good health and enough energy to get things done daily.
• Community wellbeing: about the sense of engagement you have with the area where you live

Your Community Wellbeing Field

Your Career Wellbeing Field

Your Social Wellbeing Field

Your Financial Wellbeing Field

Your Physical Wellbeing Field

CHECK THE PHENONOMENENT TO FIND OUT WHETHER YOU ARE UNDER GEOPATHIC STRESS

Disturbed sleep, nightmares, headaches and perpetual tiredness even after sleep

Family disharmony and constant arguments

Depression and psychological problems

Feel tired and exhausted to stay at home/office

Chronic ill health, candida and ME

Miscarriage and problems with conception

A failure to respond to regular medicine

Unexplained illness symptoms

Unexplained child illness, hyperactivity and temper tantrums

MS, Cancer and leukaemia

Neighbor in serious ill health

Previous house occupant of house been seriously ill

Bad luck or sudden serious disease after moving in the house

Mould or moss growing at home

Attract bees, ants, wasps , and cats at home

Crack on the wall, unusual gaps in hedges

Plants cannot grow or set fruits

Trees with cancerous knobbly growths on them nearby or trees whose trunks have split into two or twisted or trees that lean or bend to one side

If any of the above factors resonate with you – you may be geopathically stressed in some ways. If you’re still unsure, contact our health practitioner or dowser.

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