Name *

First Name

Last Name

A *

1) Do you feel isolated

2) Do you have nightmares or/and hallucinations?

3) Sore throat

4) Low immune system

5) Digestive issues and abdominal pain

6) Manic or emotional instability

7) Worry

B *

1) Do you feel disconnected

2) Do you feel mentally exhausted?

3) Tight Jaws

4) Heart palpitations

5) Low self-esteem

6) Feeling overwhelmed

7) Overthinking

C *

1) Do you suffer with sinus issues?

2) Do you lack trust with your intuition?

3) Stiff neck

4) Poor circulation

5) Inability to commit

6) Loss of imagination or creativity

7) Aches & pains in lower legs and feet

D *

1) Do you struggle to focus on a task?

2) Difficulty seeing the future

3) Creative blockage

4) High/low blood pressure

5) Inability to follow through with goals

6) Constipation

7) Lack of focus

E *

1) Do you struggle to trust?

2) Poor vision

3) Thyroid issues

4) Breathing difficulties

5) Sensitive to criticism

6) Loss of sex drive

7) Feeling abandoned

F *

1) Do you feel confused

2) Lack of imagination

3) Unable to express yourself

4) Dwelling on past relationships

5) Need to be in control

6) Back pain

7) Unable to relax or feel calm

G *

1) Do you feel dissociated from your body?

2) Inability to plan or set goals

3) Feeling lost for words

4) Holding onto grudges

5) Loss of ambition

6) Loss of sense of identity

7) Living in the past