Body Code PreTest

Name
Date

MonthDayYear
Date
Age
Email
example@example.com
Major Concern #1 (Physical, Mental, Spiritual)
Concern #1 Severity 1-10 (10 is the worst)
Major Concern #2 (Physical, Mental, Spiritual)
Concern #2 Severity 1-10 (10 is the worst)
Major Concern #3 (Physical, Mental, Spiritual)
Concern #3 Severity 1-10 (10 is the worst)
Immune System %
Heart Communication %
Brain Communication %
Spirit/Body Communication %
Vibrational Frequency % for Unconditional Love
Total # of Trapped Emotions
Total # of Heart Wall Emotions
Meridians - Check the box if the System or organ isn't happy

LiverGallbladderLungLarge IntestineHeartSmall IntestineStomachSpleenBladderKidneyPericardiumTriple WarmerGoverningConceptionPenetratingGirdleYang HeelYin HeelYang LinkingYin Linking
Toxins, Heavy Metals, Pathogens - Check the box if the System or organ isn't happy

DentalMicrobialPrionChemicalHeavy MetalExcessesElectromagneticMercuryLeadCadmiumAluminiumVirusBacteriaFungalMoldParasites
Chakras

CrownBrowThroatHeartSolar PlexusSacralRoot
Organs and Glands

Left BrainRight BrainCorpus CallosumCerebellumFrontal LobeBrain StemHypothalamus GlandPituitary GlandPineal GlandThyroid GlandLungsHeartThymusLiverGallbladderPancreasSpleenStomachSmall IntestineIleocecal ValveLarge IntestineAdrenal GlandsKidneysProstate/UterusBladderOvaries/Testicles
Joint Biological Age - List a specific joint and muscle test the age.
Should be Empty: