Quantum Spirituality Questionnaire

1
Name * This field is required.
First Name
Last Name
2
Email* This field is required.
example@example.com
3
Phone Number
Please enter a valid phone number.
4
What areas in your current life have the most room for improvement that you have decided to work with Self Heal with Liz? * This field is required.
5
How long have you been wanting to address these areas? * This field is required.
6
What life challenges are you currently facing?
7
Who else are you currently seeing for your concerns? How often do you see them? (therapist, doctor, etc)
8
Please list current medications, supplements, etc.
9
Where do you feel pain in your Body?* This field is required.
Endocrines
Arms or Legs
Organs
Chest or Back
Head or Brain
Skin
Bones
Muscles
Joints
N/A
10
Please describe any areas of discomfort?
11
What RELIEVES your pain?
12
What INCREASES your pain?
13
Do you have a regular physical exercise program? What are your favorite physical movements?
14
What are your Least favorite physical movements?
15
What are some techniques/tools you are currently using to support your Mental wellness? * This field is required.
16
Briefly describe your typical diet. How is your digestion? Daily bowel movements? (Normal, loose, constipated?) * This field is required.
17
How do you spend most of your day?* This field is required.
Driving
Sitting
Standing
Laying down
Lifting
Sleeping
18
What are your sleep habits?* This field is required.
Fall asleep easily
Trouble falling asleep
Stay asleep easily
Trouble staying asleep
I remember my dreams
I do not dream
Unrested
sleep too much
Other
19
Which Character can you relate to the most?* This field is required.
Negative Nuts
Angry Almond
Worried Watermelon
Depressed Donut
Grieving Ginger
Joyful Jackfruit
Fearful Fig
20
Are you aware that your nervous system has two modes?* This field is required.Pick Which Mode you spend the most time in
Sympathetic (fight/flight/Functional Freeze))
Parasympathtic (Rest/ Digest/ Repair/ Innate Healing)
21
What aspects of your life provide you the most joy & pleasure? * This field is required.
Huge
Large
Normal
Small
Ok
Ok
22
If you could change or improve one thing, what would it be?
23
In willing to start doing things differently, how do you WANT to think, feel and experience life?PHYSCIALLY, MENTALLY, EMOTIONALLY, SPIRITUALLY
Huge
Large
Normal
Small
Ok
Ok
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