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01. Full Name*

02. Email*

Enter Email Confirm Email

03. Mobile*

04. WhatsApp Number

05. Country*

06. Age*

07. How did you hear about us/our program?*

The name of the friend who referred you*

The name of the event where you heard of us*

The name of the media segment/story where you heard of us*

Where did you hear of us?*

08. How do you feel about incorporating prayer & scripture into your healing program?*

09. What best describes your spirituality?*

Christian
Spiritually Aware
No Spiritual Affiliation
Other Spiritual Affiliation

Please share your Spiritual Affiliation*

10. Which best describes your issue?*

Check ALL that Apply and Specify diagnosis/any pertinent details below

Other Issue:*

Describe your issue in detail*

11. If you have Fibroids, how many and what sizes are they according to your most recent tests and when did that take place?*

As much as possible, please provide exact details on the number, size and location if known.

12. If you have Gut Issues, which of the following do you experience?*

Check ALL that Apply and detail how you experience it below

Bacterial Vaginosos – BV
Bloating
Constipation
H. Pylori
Yeast Infections
Other

Other Gut Issue:*

Describe your gut issues in detail*

13. Medical overview of your story/case*

Please include dates to provide a timeline where possible–also identifying any surgeries and/or advanced reproductive technology treatments (such as IUI or IVF) you have undergone.

14. What are your most severe symptoms?*

15. Please detail the following regarding your monthly cycle:

Duration — How many days does it last? Please include a range if it is not an exact number. Ex. 3 to 5 days:*

Frequency — How often does it occur? Ex. 28 days or 28 to 31 days:*

15. Bleeding — How heavy is your bleeding on a scale of 1 - 5. Please break down your bleeding for each day of your cycle.

Day 1:*

Day 2:*

Day 3:*

Day 4:*

Day 5:*

Day 6:*

Day 7:*

16. Cramping/Pain — How painful is your cramping on a scale of 1 - 5. Please break down your cramping pain for each day of your cycle.

Day 1:*

Day 2:*

Day 3:*

Day 4:*

Day 5:*

Day 6:*

Day 7:*

17. Please indicate if and when you take painkillers and if so what kind:*

18. What is your current emotional condition?

First Choice
Second Choice
Third Choice

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