"HEALTH FROM WITHIN" Workshop Registration Form

Classes Are For Informational Purposes Only

Name

First NameLast Name

Address

E mail Address (REQUIRED FOR CLASS ACCESS)

example@example.com

Home

Cell

Work

Date of birth

Date

Age

Medical Information/Symptoms

How many siblings do you have?

Which child are you in family? First born, etc

How many kids do you have?

Are you married, single, divorced, or widowed?

married, single, divorced, or widowed?

Where were you born?

If not in USA, what year did you immigrate to the USA?

in USA, what year did you immigrate to the USA?

Have any of your immediate family members deceased? If so, please state relation, date, and cause of death

Relation

Deceased on

Cause of Death

Relation

Deceased On

Cause of Death

Name

Phone

Name

Phone

Other Personal Information You Want To Share

How did you hear about the workshop?

Have you ever had any of the following symptoms or signs, seen a health care provider, had treatment recommended, received treatment, or been hospitalized for any of the following

Brain/ Nervous System- frequent and/or sever headaches, migraines, seizures, epilepsy, dizziness, {yes}{orNo}

weakness, fainting, numbness/tingling, head injury, stroke, memory loss, loss of consciousness, etc {yes}{orNo}

1. Brain/ Nervous System frequent and/or sever headaches, migraines, seizures, epilepsy, dizziness, weakness, fainting, numbness/tingling, head injury, stroke, memory loss, loss of consciousness, etc.. YES OR NO

Heart/ Circulatory System - chest pain, high or low blood pressure, heart disease, heart attack,

2. Heart/ Circulatory System chest pain, high or low blood clot, anemia, etc YES or NO

Lungs/ Respiratory System - allergies, asthma, difficulty breathing, shortness of breath, chronic

YES

Urinary System-kidney, bladder, stones, etc YES

or NO

Pregnancy- (females only) are you currently pregnancy? YES

YES

Musculoskeletal System - injury or disorder of joint/tendon/ligament/disk, weakness of

back/spine/joint, physical handicap, arthritis, internal fixations (i.e. pins, screws), etc

6. Musculoskeletal System injury or disorder of joint/tendon/ligament/disk, weakness of back/spine/joint, physical handicap, arthritis, internal fixations (i.e. pins, screws), etc

Sensory Organs- diseases, infections, problems of the eyes (sight) blurred vision, ears (hearing) nose (breathing), etc {yes} {orNo}

Have you ever had cancer, tumor, leukemia, or cyst? {yes} {orNo}

2. Have you ever had cancer, tumor, leukemia, or cyst? YES

Nervous, Mental, Emotional, Behavioral eating disorder, anorexia/bulimia, depression, anxiety, alcohol or substance abuse, abuse/dependency, member of a support group, chemical imbalance, attention deficit disorder, schizophrenia, obsessive compulsive or panic disorder, etc YES

Have you had any type of herapy/counseling session in the past? If yes, for how long? When was your last session? therapist? YES

Are we authorized to contact your physician or

Have you been hospitalized for any reason in the last 5 years? YES

5. Have you been hospitalized for any reason in the last 5 years? YES

or NO

Are you currently on any form of prescribed medication? YES

6. Are you currently on any form of prescribed medication? YES

or NO

Have you ever attempted or thought about suicide? YES

7. Have you ever attempted or thought about suicide? YES

Have you ever used any illegal drugs, controlled drugs, substances, or been diagnosed as chemical

or alcohol dependent. If yes, when was your last intake?

8. Have you ever used any illegal drugs, controlled drugs, or alcohol dependent. If yes, when was your last intake?

Have you ever seen or consulted any doctor or health care provider for any other symptoms or

conditions. If yes, list them here

9. Have you ever seen or consulted any doctor or health care provider for any other symptoms or

REGISTER TODAY!!! Choose The Full Workshop of 9 Series Or Individual Series (Each Series Is 4-6 Classes) 7PM -10PM

Private One on One Session $260 ( Book 10 Sessions for 10% Discount)

Series 1 Goal Setting & Manifestation $250

Series 2 Communication & Art of Listening $250

Series 3 Knowing Who To Trust $250

Series 4 Overcoming Ups & Downs In life $250

Series 5 Improve Conditions of Life $250

Series 6 Mindset To Wealth & Prosperity $250

Series 7 Self Values & Integrity $250

Series 8 Relationship WIth Self & Others $250

Series 9 Wealth & Financial Freedom $250

Health From Within Workshop Includes All 9 Series (Most Popular)

2250.00 USD with $300 Discount TOTAL ONLY $1,950!

Class Dates: Nov 30th, Dec 7th, Dec 14th, Jan 4th, Jan 11th, Jan 18th

You will receive all class notifications, information, materials, location, and links via email.

I, the aforementioned, have thoroughly read and understand the written information in this registration form pertaining to the workshop I have registered for. I take full responsibility for participating in the workshop.

Signature

Please list 3 personal goals you wish to achieve by the end of the workshop you have registered for:

1.

2.

3.

F fealth From Within

Workshop Registration Form

GOALS:

SEE YOU IN CLASS!