BLISS INNER WELLNESS

Bliss out with

Kim Mallory
Please complete this form with as much detail as you can and submit prior to your session. Your information is important to me and will be held in the upmost confidence.
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number*
E-mail*
example@example.com
Date of Birth*

MonthDayYear
Age*
What do you wish to achieve?*
What are your current main concerns? body / mind / spirit*
Please briefly tell me your history (injury | trauma | surgeries etc.)*
Are you currently seeing any healthcare professionals?*
How are you sleeping? (How many hours, quality etc.)*
Please read the list and tick any that you are currently feeling or have felt over the last 3 months*

CriticisedOverwhelmedApprehensiveUncertaintyAgitatedParanoidIntolerantMuddledGuiltyOverworkedAggravatedParalysedDepressedRejectedEasily IrritatedPersecutedHelplessAnxiousHopelessUneasySadDepressedGrievingAbusedFearfulUnable to GrieveDistressImpatientAngryWorriedOutragedSleeplessNervousRestlessIntimidatedNONE
Do you have any concerns about the following areas - please tick and comment below

DigestionRespiratoryCardiovascularUrinaryNervous SystemMuscle / JointsLymphatic SystemEndocrine System
Please give further details in relation to any areas ticked above or anything else you feel I should be aware of.

Please take a moment to consider the following.*

Please take a moment to consider how much time you have for each of the following.*

Bliss out with