Sorry, you have Javascript Disabled! To see this page as it is meant to appear, please enable your Javascript!

Skip to content

Natural health balance

Home
- Profile
- Holistic therapy
Contact/Booking
Services
Courses
Retreat
Events
Shop
Blog
My account
- Login

Search for:
0

Home
- Profile
- Holistic therapy
Contact/Booking
Services
Courses
Retreat
Events
Shop
Blog
My account
- Login

Search for:

Health questionary

Home
Health questionary

Health questionnary

We will advice you the therapy to book according to your answers.

Email *

Number

(copy)

(copy)

Prefered location (9am~7pm)

Mitaka: Sun, Mon, Tue, (Wed)・Thu: OFF・Uenohara/Yoyogi: on request

The session is for

Main domain of consultation

Service you are interested in

Details for the main reason to consult (physical)

Back ache, muscle pains
Breathing issues
Circulation (blood, lymphatic), heavy legs
Chimiotherapy / radiotherapy (relief & support)
Covid (after effects)
Digestive disorder, allergies, IBS
Fatigue
Food disorder, weight issue
Heart issues
Hormonal, gynecologic
Improve my physical performance, flexibility, posture
Stress, anxiety
Sleep disorder
Skin problems, eczema, allergies
Trauma (physical): accident, injury

Details for the main reason to consult (psychological, emotional, energetic)

Anxiety, panic, depression
Emotional (fear, anger, worry)
Energy unbalance, entity
Feeling stuck, lack of meaning
Intimacy, sexuality
Lack of focus, Learning difficulties, memory, DYS
Mourning, recent loss, mediumnity
Phobia, addiction
Relational trouble
Space (home) energy purification (radiesthesy, geobiology)
Trauma (psychological)
other

What is your need / goal / expectation for a session?

Sports

Diet

Details

Lots of meat
Coffee in excess
Alcohol (more than casualy)
Tabaco
Allergies / intolerance
Eco-anxiety related to food
Eating disorder

Elimination・Digestion・Allergies

Urine: did you notice any color change?

Tong: color on the top

Skin: any color change, texture?

Eyes: any change recently?

Gyneco / Uro

Medical history

Heart, breathing issue, operation, fracture, twisted anckle, pathology, psychiatry

Important informations

Recurring pains, loss of a relative, major event or trauma, sensitive subject

How do you feel at work (if you do work)?

Comfortable
Uncomfortable

If uncomfortable, please details below.

How do you feel in your living environment? (home)

Comfortable
Uncomfortable

If uncomfortable, please details below.

How is your relationships? (partner, family, collegues, with yourself…)

Any QUESTIONS, specific request?

Name

Thanks for filling the form, we will get back to you soon.

*Any informations share here are confidential and will stay between you and your body mind therapist.

OTOMI THERAPY

Natural health balance for you and your family.

About
Reviews

BODY MIND THERAPY
Kinesiology
Massage
Reiki
Sonotherapy
Dance Therapy

BLOG Conscious Health

SCHOOL
Reiki course
Sound meditation
Do-in self care

RETREAT Wellness nature

Français
日本語

CONTACT
Health questionary

SHOP Natural Health

Copyright © 2022 Designed by EmmanuelleValette - Privacy Policy & Terms of services Photography ©DorianeLetexier

Select your currency

JPY Japanese yen

USD United States (US) dollar

INR Indian rupee

GBP Pound sterling