Post-Healing Symptom Report
Questions marked by * are required.
1.
Client First Name (Optional):
2.
What is the PRIMARY reason for which healing was sought? (list any official diagnoses here): *
3.
Please estimate the symptom/discomfort level PRIOR TO working with LD: (click the drop down menu) *
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1 (Least Severe)
2
3
4
5
6
7
8
9
10 (Most Severe)
4.
Please estimate the symptom/discomfort level IMMEDIATELY AFTER working with LD: (drop down menu) *
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1 (Least Severe)
2
3
4
5
6
7
8
9
10 (Most Severe)
5.
If you worked simultaneously with any other medical/ healing provider, please list here:
6.
OPTIONAL: BRIEFLY describe any changes or improvement in symptoms.