Health History

1

Name* This field is required.

First Name

Last Name

2

Date of Birth

3

Email* This field is required.

example@example.com

4

Whatsapp NumberIn case my email ends up in spam.

Country code eg. +1

Phone Number

5

What’s currently going on in your body that you’d like support with?* This field is required.Eg. Any pain, imbalance, tension, emotional overwhelm, whatever’s true for you

6

How long have you been dealing with these issues?

Eg. Lower back pain: 4 years, insomnia: 10 years

7

Rate your pain or discomfort from 1-10.

1
2
3
4
5
6
7
8
9
10

Doesn't affect my life

Affects every area of my life

8

What have you tried so far to find relief and what were the results?* This field is required.

9

If I could transport you into the future, 6 months from now, what would be an amazing result for you?Eg. Able to put on my shoes, sit on the floor with my kids, sleep well, feel at ease in my body

11

Are you ready willing and able to spend $150 USD for a transformative live session with Dr. Kim?* This field is required.Discounts available for session packages

Yes

No

12

Is there anything else you would like me to know?