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Energy Reality Energy Healing Support for Health
Please provide the following information to assist with the healing.
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Email
*
Your email
Name of person filling out form:
*
Your answer
Address:
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Your answer
Name of person to receive this healing. TYPE FULL NAME (not "myself" or other words) and use same spelling in all daily reports. (All information organized around this input.):
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Your answer
Please DAILY rate the following symptoms so that I can monitor your progress. This helps me to adjust the healing energies for optimal support. PLEASE UPDATE THIS DAILY, if you can.
Date (for which symptoms reported)
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MM
/
DD
/
YYYY
Please rate COUGH on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
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Severe
Please rate DIFFICULTY BREATHING on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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Severe
Please rate FEVER or CHILLS on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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Severe
Please rate HEART PALPITATIONS / STRESS on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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10
Severe
Please rate TIREDNESS / FATIGUE on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
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Severe
Please rate ACHES & PAINS on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
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Severe
Please rate SORE THROAT on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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Severe
Please rate NASAL CONGESTION, RUNNY NOSE on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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10
Severe
Please rate DIARRHEA / GASTROINTESTINAL ISSUES on the following scale (0=None/Resolved, 5=Moderate, 10=Severe):
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None/ Resolved
0
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10
Severe
Optional: You may enter brief comments or additional information.
Your answer
Remember to come back tomorrow, or as soon as possible, and SUBMIT ANOTHER RESPONSE with this form to give an update so that I can optimize your healing support.
After filling out this form, press the SUBMIT button below so that I receive the information.
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