Pain Free Living Questionnaire

WELCOME TO PAIN-FREE LIVING!
At the International Chronic Pain Institute™ we understand that it can be very frustrating and confusing to try and figure out why you have chronic ongoing pain and how to get rid of it, especially if you've consulted with medical doctors and nothing is showing up on medical tests, you've seen "alternative" healthcare practitioners, had Physical Therapy, and tried endless "natural" health solutions, but nothing has helped you to stop the pain.

We realize that you probably feel stuck and like you’ve tried everything to figure this out.

It’s like laying out a million confusing puzzle pieces and not seeing how to put them back together properly.

We will help you put your pain puzzle together and show you exactly how to remove the hidden root cause of your pain, and we’ll show you how to do this without ever asking you to take a single drug, supplement, endless physical therapy, or having to eliminate the foods you love. We're experts at this!

FILL OUT this brief Pain Free Living Questionnaire Now.

Debora and her trusted Program Advisor will personally review it and send you recommendations to help you get UN-stuck and get your Energy and life moving forward on the path to Pain Free Living.
Name*

First NameLast Name
Email*
example@example.com
Best Phone Number

Area CodePhone Number
Where did you hear about Debora?*
Country*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Age*
Occupation
1. What is your most urgent #1 pain and/or symptom? *
2. What do you think has caused this?*
3. What else is not working? What other pains, problems, patterns, complaints, symptoms, illnesses, injuries, issues are going on that you want to stop?*
4. What do you think is the biggest obstacle or challenge that is stopping you from being able to heal your pain and symptoms and get to where you would like to be?*
5. If Debora had a magic wand and could instantly make your pain go away and you didn't have to figure out the "How", describe what your ideal body, mind, health, life would look like, feel like, be like, without pain.*
6. If you were asked to listen to an Mp3 recording once each week followed by a written exercise, as part of a plan to remove your pain and get your energy back:*

a. I would absolutely do this every week because I am 100% committed to doing whatever it would take to heal my pain.b. I would consider doing this after I understood why, because I’m open to trying new things that make sense.c. I would never do this because I’m way too busy and I don’t see how this could possibly help my pain.
7. Which calls/classes/programs have you attended with Debora?*

Heard her speakHighSpeed Healing WednesdaysThe Day of HealingThe Pain Free Living ProgramBiofield Healing Practitioner Training ProgramOther
On a scale of 0-8 (8 meaning I’m VERY Ready & Willing)
How ready and willing am I to invest the following in order to become pain free?

My Time*

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Energy*

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Money*

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

My Heart and Soul To do Whatever it takes to Become Pain Free and Get My Energy & Life Back on Track!*

	1	2	3	4	5	6	7	8

1 is Not Ready, 8 is Totally Ready

Additional Comments For Debora
Should be Empty:

WELCOME TO PAIN-FREE LIVING!