Personal online
healing from Jewish tradition
If you have any questions about this form, email us at jewishealing@yahoo.com
After you have completed this form to the best of your ability
click on the "Submit Query" button below
You can keep typing if you wish beyond the size of each question box.
Your full name:
Your E-mail address
:
Street Address
City
State
Zip
Age
Sex
Height
Weight
Marital Status
1. Describe the symptoms you are experiencing
2. How long have these symptoms been going on
3. How was this illness first discovered?
4. What tests have you gone through to diagnose this illness
5. How did your doctor or therapist, etc. diagnose this illness?
6. What medications (if any) were prescribed? Are you still taking them?
7. What other treatments have you received? (surgery, physical therapy, etc.)
8. List any other health care practitioners that you have seen for this disorder
Please type "yes" or "no" to answer the following questions
9. Do you smoke?
10. Do you drink alcohol excessively?
11. Are you frequently hungry?
12. Are you frequently thirsty?
13. Are you often too hot?
14. Are you often too cold?
Click the "Submit Query" button below.
Once we receive your response to this questionnaire we will reply with 24 hours to let you know how we can help you. Meanwhile, click the "Next page" button to view the fees page to choose an appropriate type of payment.
