Wellbeing Questionnaire

Thank you for your enquiry. I look forward to working with you. To help prepare for your appointment and maximise your time spent with me, please fill in the questionnaire below. Not every answer is compulsory, but please try and give as much information as you can. All information shared will be treated as confidential and will not be shared with anyone else.

First Name

Email Address

What Is Your Occupation?

Your Current Relationship Status?

Last Name

Date of Birth (optional)

WHAT IS YOUR AGE?

Number & Type of Dependents

Reason for appointment? What is your goal?

If you take medication – what it is/how much/and for how long have you been taking it for?

Any supplements – what they are/how much/and for how long have you been taking them for?

Any operations, what were they for/and how long ago?

List all symptoms of the mind, body or soul stating how long you have had them for. Include skin conditions/sleep problems/repetitive negative thinking/grief/post traumatic stress/anxiety/fears/phobias/depression/self-harm/unfulfilled/empty/no life purpose etc.

Any relationship issues – abused/bullied/co-dependent/controlled/jealous/insecure/ lonely/deep withheld secrets/guilt/shame etc.

Any patterns of behaviour - obsessive/angry/passive-aggressive/manipulative/ negative/low self-esteem/no confidence/inferiority/superiority complex/self-loathing etc.

Any addictions – relationships/recreational drugs/prescription drugs/alcohol/food/etc.

Any allergies/sensitivities – animal dander/hay fever/dairy/wheat/gluten/seafood/ candida/etc.

About your diet/whether you skip meals/go for long periods without food/binge eat/are bulimic/eat mainly junk and fast food/eat healthy etc.

Have you any amalgam fillings? How many? And since when?

Have you had root canal treatment? How many? And when?

Any request for spiritual development – increased intuition/insight/chakra balancing/karmic/past life cleanse etc.

Have you any limiting beliefs?

Is there something from your past you haven’t let go of?

What is bothering you?

What are you in denial of?

What are you fearful of?

Any regrets?

Is there anything you are in conflict with? Past? Present? Future?

What are you not dealing with?

What anxious or negative thoughts do you have about the future?

Is there anything that you think you cannot resolve?

How would you describe your lifestyle?

Is there something missing from your life?

Is there anything else you think I should know?

Initials

Today's Date

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

Thanks for submitting! I'll be in touch within 24 hours. Until then, all the very best, Jill x