Self Evaluation Feedback
Pre and Post healing session :
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Number of healings
please ignore if it is your first healing
Your Name
*
First Name
Last Name
Gender
*
Male
Female
Other
E-mail
*
Mobile Number
*
-
Area Code
Phone Number
Option 1 -Physical, Option 2 - Emotional , Option -3 Mental & Option all -Holistic
*
Please Select
Option 1
Option 2
Option 3
Options all
You select one of the options for self evaluation
Option 1 - Physical Body Aches
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 1- Physical Headaches
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 1- Physical Any existing symptoms
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 1- Physical Spinal Problems
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 1- Physical Digestion
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 1- Physical Nervous systems
*
Worst
1
2
3
4
5
6
7
8
9
Best!
10
1 is Worst, 10 is Best!
Option 1- Physical (any other specify in final comment below)
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 2- Emotional Sadness
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
Option 2- Emotional Anger
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2= Emotional Frustration
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Depression
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Anguish
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Irritability
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Hatred
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2= Emotional Jealousy
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Stress levels
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 2- Emotional Resentment
*
Worst
1
2
3
4
5
6
7
8
9
Fantastic
10
1 is Worst, 10 is Fantastic
Option 3- Level of Mental Clarity
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Level of concentration
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Memory power
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Ability to plan and organise
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Perception
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Discernment
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental Comprehension
*
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Option 3- Mental (any other specify in final comment below)
Not at all
1
2
3
4
5
6
7
8
9
Definitely
10
1 is Not at all, 10 is Definitely
Physical problems
*
Rows
Not applicable
Feeling discomfort
Somewhat discomfort
Mostly no pain
Definitely comfortable
Before healing
After healing
A day after healing
Emotional Problems
*
Rows
Not applicable
Feeling discomfort
Somewhat discomfort
Mostly no pain
Definitely comfortable
Before healing
After healing
A day afer healing
Mental Problems
*
Rows
Not Applicable
Feeling discomfort
Somewhat discomfort
Mostly no pain
Definitely comfortable
Before healing
After healing
A day after healing
Other
*
Rows
Not applicable
Feeling discomfort
Somewhat discomfort
Mostly no pain
Definitely comfortable
Before healing
After healing
A day after healing
How do you feel overall after treatment ?
Terrible
1
2
3
4
5
6
7
8
9
Great
10
1 is Terrible, 10 is Great
Any final comments?
Optional: Contact Details
Landline /any other
Phone Number
-
Area Code
Phone Number
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