Client Questionnaire

  • Please return this questionnaire at least one day before your initial consultation. The information that you provide is completely confidential, and will only be read by Marc Blausten.
  • PERSONAL INFORMATION

  • PHOTOGRAPH

    Please upload a recent photo of yourself. Required for Distant Healing. Allowed file types are: jpg, gif, png, pdf, docx, doc
  • Drop files here or
    Accepted file types: jpg, gif, png, pdf, docx, doc, jpeg.
  • MEDICATION

    List any current medication. Include contraception and any other routinely taken medicines.
  • MEDICAL HISTORY

    List all major illness’s, injuries and times hospital in chronological order : Please include births, and any recurring infections or conditions.
  • GENERAL

  • This form collects your name, telephone number and email address along with your message so that our team can communicate with you and provide you with assistance. Please check our Privacy Policy to see how we protect and manage your submitted data.
  • This field is for validation purposes and should be left unchanged.

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