Health Waiver | SIMIN LIANG

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Health Waiver

Please take a moment to fill out the form.

First Name

Relationship

Last Name

Birthday

Email

Code

Phone

Select an Address

Emergencay Contact

Emergency Contact Telephone

Doctor's name

Last Check up

Doctoer's Address

Medications being taken

Health Problems (past&current)

Choose the challenges you are facing

Addictions

Smoking

Drugs

Gambling

Compulisve Behaviour

Anxiety

Depression

Sadness

Stress

Fears

Phobias

Panic Attacks

Guilt

Relaxation

Eating Problems

Food/Diet Weight

Problems Anorexia

Bulima

Exercise

Interview

Money Block

Skills Nerves

Public Speaking

Concentration

Exams

Memory

Driving

Sexual Problems

Fertility

IVF

Conception

Pregancy

Birth

Pain Control

Hearing

Sight/Vision

Mobility

Skin Problems

Hair Growth

Relationship

Childhood Problems

Sleep Porblems

PMDD

Others

Describe your dream day and life wihtout any problems

Your Signature

Thanks for submitting!

©2024 by Transformational Therapist Simin

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