Energy Healing
Name
Fill out the contact questionaire and click submit button or email me at the link below

Email:
jim@jk-energyhealing.com
Phone
Email
Street
City/Town
Zip
Date of Birth
Age
Occupation

Please answer the questions below that pertain to your particular ailment.
How did you hear about me?
Describe the problems for which you are seeking healing assistance
How long have you had these problems?
Do you smoke? If quit, how long ago?
Please briefly state past medical history including surgeries and accidents
What medications are you on?
What health care professionals are you seeing now?
Are you having pain now? If so, where is it located and what is the intensity of it with 10 being the worst?
Please list any other information that you feel will be helpful


©Copyright 2008 by Jim Kupczyk. All rights reserved.