First Name Surname Marital Status Married Single Divorced Widowed Gender Male Female Other Address Email Address Mobile Number Date of Birth Time of birth Birthplace Are you currently experiencing any physical or emotional issues? Yes No If yes, please describe: Do you have a history of any medical conditions? Yes No If yes, please specify: Are you currently taking any medications? Yes No If yes, please list: Do you consume alcohol? Yes No Do you smoke? Yes No Do you use recreational drugs? Yes No Have you practiced any form of alternative healing or energy work before? Yes No What challenge(s) are you are currently experiencing? Physical Discomfort Emotional Imbalance Lack of Energy Difficulty in Relationships Other(s) Explain your motivation for seeking a Chakra Diagnosis? Privacy Policy I have well read, understood and agreed to the privacy policy of Vana Natural Healers. Refunds and Returns Policy I have well read, understood and agreed to the Refunds and Returns policy of Vana Natural Healers. Terms and Conditions I have well read, understood and agreed to the Terms and Conditions of Vana Natural Healers. Send
