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Birthday
Jour
Mois
Année
  1. Wellness Goals

Please indicate your wellness goals
  1. Health and Medical Information

(This is to make sure you check with your primary physician prior to starting any therapy especially if you answer yes to any of the following:)

Do you have any chronic health conditions?
yes
no
Are you currently taking any medication?
yes
no
Do you have any allergies?
yes
no
Have you ever experienced claustrophobia?
yes
no
Are you pregnant?
yes
no
Do you currently engage in any wellness or fitness activities?
yes
no
On a scale of 1-10, how would you rate your current stress level?
On a scale of 1-10, how would you rate your current energy level?
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