Please take some time to fill out the chakra questionnaire below prior to your first session. This form is designed to help me learn more about your energy centers, and will remain confidential. With regards to the questionnaire, most questions are two fold. Select only one answer for each question. Remember that this questionnaire is meant to help me to understand more about you so I may customize your nutritional healing and create harmony in your physical and energetic body. Don’t rush through the questions, rather try to reflect on each question before answering. Honestly answer each question to be true at least 90% of the time.

Name *
1. Are you comfortable with your physical body and are you rarely sick?
2. Are you self-motivated and do you achieve most of your goals?
3. Are you very passionate about most things and willing to fight for just causes?
4. Do you have a strong drive to live and do you feel that you have a right to exist?
5. Are you free from asthma as well as allergies (such are skin conditions, candida, yeast infections, etc.)?
6. Are you very creative with your mind and do you have the ability to see situations from different perspectives (mentally and emotionally)?
7. Are you confident, enthusiastic and outgoing and are you able to spread joy to others with a constant positive outlook on life?
8. Are you connected to your emotional self and do you understand that feeling and expressing your emotions are your right?
9. Are you free of digestive problems such as ulcers, food intolerances, constipation or diarrhea, blood sugar disorders, sluggish liver, etc.?
10. Are you mentally strong and clever and do you have an exceptional memory and learn new things quickly?
11. Can you truly say your ego is in balance and are you confident enough that you easily admit when you are wrong?
12. Does your belief system include knowing that a higher power exists and do you use your personal power to openly discuss your beliefs?
13. Is your breathing deep and when stressful situations arise does your breathing pattern remain constant?
14. Can you say no to people without feeling guilty or remorseful?
15. Are you friendly and compassionate and do you rarely gossip?
16. Are you a loving and giving person with little thought of receiving back and are you free of jealousy and envious thoughts?
17. Do you rarely have sore throats, shoulder and jaw tenseness or problems expressing yourself?
18. Are you very organized and do you have a good ability to plan and give orders?
19. Do you consider yourself a person with high integrity and are you devoted and loyal?
20. Do you always communicate your inner truths and are you open and honest with others regardless of the situation?
21. Do sleep well and are you able to get out of bed in the morning easily with no problems?
22. Do you trust your intuition and insights and do you have a good imagination without losing contact with reality?
23. Do you have a deep understanding of your existence that allows you to have little fear or anxiety in your thoughts?
24. Are you connected to your unconscious self and do you have a strong intuitive (psychic) awareness?
25. Does your body feel and smell clean and is your lymph system flowing freely?
26. Do you consider yourself a visionary and is your creativity and inspiration unlimited?
27. Are you spiritually aware and are you in balance with your masculine and feminine energies?
28. Do you believe in enlightenment and the universal consciousness and do you feel you have a purpose and a spiritual knowingness?