Comprehensive Health ScanQuestionnaire

This scan is to invite clarity, openness and integrity to serve your body awareness and health.

It may indicate strengths and stress points in your health profile, to live a life of radiant health and fulfillment.

It is a kinesiological-intuitive indication. It does not identify disease or prescribe medication.

Consider it a starting point for your own research, healthy living, and specific diagnostic tests.

Name: ______Date: ______Age ______

Email: ______Phone ______

What do you consider your health strengths? ______

What do you consider your health weaknesses? ______

Do you have any medically diagnosed conditions? ______

Are you currently on a particular diet? YES NO If yes, please describe.

______

What is your water source? Approximatelyhow many ounces of water do you drink per day?

______

What oils do you use in your food?

______

Have you been exposed to any of the following?

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  • Vaccines
  • Emotional Trauma
  • GMO foods
  • Heavy Metals
  • Herbicides
  • Pesticides
  • Pharmaceuticals
  • Solvents
  • Stress
  • Chemtrails

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Do you suffer from any of these health issues?

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  • ADHD
  • Alzheimer’s disease
  • Adrenal Fatigue
  • Auto-Immune disease
  • Belly flab / Midriff bulge
  • Bloating after meals
  • Brain fog
  • Cancer
  • Constipation
  • Depression
  • Diabetes
  • Food Intolerances
  • High Blood Pressure
  • Heart Disease
  • IBS (Irritable Bowel Syndrome)
  • Kidney Disease
  • Low fertility
  • Memory lapses
  • Multiple Sclerosis
  • Obesity
  • Parkinson’s
  • SIBO (Bacterial Overgrowth)

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Informed Consent

I hereby employ Jane Barthelemy for the purpose of improving my health and to increase my own awareness of my body and health. I understand that the sessions offered by Jane Barthelemy are not a replacement for medical treatment when necessary.

I understand that Jane Barthelemy uses a combined approach of muscle testing with vials and intuitive energy healing, in a non-invasive, safe, and objective protocol, using the body’s own innate intelligence to re-establish communication with itself. I understand that intuitive healing and kinesiology are not always correct. Therefore I agree to provide clear feedback to Jane regarding what I am experiencing with her treatments and recommendations

I understand that Jane is not a medical doctor. I understand she may recommend whole foods to promote my healing, and that she does not diagnose conditions or prescribe medications. Therefore, I will not interpret any statements by Jane as a diagnosis or prognosis.

I understand that Jane’s healing sessions are voluntary and that at all times I may choose to end my participation. I understand that my health, safety and care are ultimately my responsibility.

By signing below I agree to sessions from Jane Barthelemy with this understanding.

Print Name:

______

Client Signature:

______

Date:

______

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