Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Current

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

What's your birthdate?

MM

DD

YYYY

Support Person or Partners Name

First Name

Last Name

Support Person or Partners Phone

(###)

###

####

What's your physical frame?

Select up to two options that best describes the way you've been most of your life.

thin, lanky, slender

medium, symmetrical build, athletic

larger, round, stocky

What's your weight?

Select up to two options that best describes the way you've been most of your life.

thin, hard to gain

medium

heavy, easy to gain

How much hair do you have?

Select up to two options that best describes the way you've been most of your life.

average

thinning + bald

thick

What's your hair color?

Select up to two options that best describes the way you've been most of your life.

light brown, blond

auburn, reddish, early greying

dark brown, black

What's your hair texture like?

Select up to two options that best describes the way you've been most of your life.

dry, frizzy, thin

straight + fine

oily, wavy, thick

What's your skin texture?

Select up to two options that best describes the way you've been most of your life.

dry, rough, cold

soft, normal to oily, warm

oily, moist, thick

What's your complexion like?

Select up to two options that best describes the way you've been most of your life.

darker, tans easily

pink, red, sunburns easily

pale

What are your teeth like?

Select up to two options that best describes the way you've been most of your life.

large, thin gums

small, medium, tender gums

healthy strong gums, white

What is your nose like?

Select up to two options that best describes the way you've been most of your life.

uneven, deviated septum

long, pointed, red nose tip

short, rounded, button

What are your eyes like?

Select up to two options that best describes the way you've been most of your life.

small, brown, nervous, active

medium, green, hazel, sharp

big, dark, blue, clear, calm

What are your nails like?

Select up to two options that best describes the way you've been most of your life.

dry, brittle, break easily

sharp, flexible, pink, shiny

thick + smooth

What are your joints like?

Select up to two options that best describes the way you've been most of your life.

thin, stiff, crack

loose + flexible

large + cushioned

What's your digestion like?

Select up to two options that best describes the way you've been most of your life.

gas, bloating, constipation

quick, heartburn, acid reflux

indigestion

What's your usual elimination?

Select up to two options that best describes the way you've been most of your life.

dry, hard, constipated

many, loose, normal

heavy, thick, slow, regular

How often do you sweat?

Select up to two options that best describes the way you've been most of your life.

rarely

frequently

moderately

What's your mental activity like?

Select up to two options that best describes the way you've been most of your life.

quick, restless, active

sharp, critical, aggressive

calm, steady, slow, stable

What's your memory like?

Select up to two options that best describes the way you've been most of your life.

good near + poor distant

distinct + sharp

slow + sustained

What's your intellect like?

Select up to two options that best describes the way you've been most of your life.

distracted, quick, faulty

focused + accurate

sow, steady, exact

What are your dreams like?

Select up to two options that best describes the way you've been most of your life.

fearful, active, quick, flying

aggressive, heated, adventurous

watery, romantic, relationships

How's your sleep?

Select up to two options that best describes the way you've been most of your life.

light + interrupted

little but sound, medium

sound, deep, long

What's your speech like?

Select up to two options that best describes the way you've been most of your life.

quick + can miss words

sharp, direct, strong

slow, clear, monotonous

How are your emotions + moods?

Select up to two options that best describes the way you've been most of your life.

fearfull, anxious, flexible, indecisive

anger, denial, determined, jealous

calm, depressed, attached

How's your confidence?

Select up to two options that best describes the way you've been most of your life.

shy + timid

outwardly self-confident

inner confidence

What are your relationships like?

Select up to two options that best describes the way you've been most of your life.

many, casual, clingy

intense + jealous

long, deep, secure

When threatened you tend to?

Select up to two options that best describes the way you've been most of your life.

run

fight

make peace

What's your sex drive like?

Select up to two options that best describes the way you've been most of your life.

variable + low

moderate

strong

What's your physical activity like?

Select up to two options that best describes the way you've been most of your life.

hyperactive

good + athletic

lacking + sedentary

What's your relationship to routine?

dislike routine

eager to plan + organize

prefer a routine

How's your appetite?

Select up to two options that best describes the way you've been most of your life.

irregular

sharp + strong

slow + steady

How fast do you eat?

Select up to two options that best describes the way you've been most of your life.

fast

medium

slow

What temperature do prefer your food + drinks?

Select up to two options that best describes the way you've been most of your life.

warm

cold

What is your ideal weather?

Select up to two options that best describes the way you've been most of your life.

warm + moist

cool + dry

warm + dry

How do you manage your finances?

Select up to two options that best describes the way you've been most of your life.

doesn't save + spends a lot

saves + spends a lot

saves + accumulates wealth

How charitable are you?

Select up to two options that best describes the way you've been most of your life.

donates small amounts

rarely or never donate

regular giver + very generous

Checkbox *

by checking this box, I agree to the confidentiality and liability release terms as listed above