Client Information Form

HEALER NISHANT

on a scale of 0-10, kindly rate the intensity of the problem. example: in case of body pain, if its too intense you could say it to be closer to 7 or 8 or even 10.
just remember: higher the number, worse is the condition.

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How did you hear about this site? *

Internet Search Advertisement Friend Other

If Other please specify Or If its a friend please mention h(is)er Name or Number: *

What is your age? *

Less than 13 13-18 19-25 26-35 36-50 Over 50 Prefer not to say

What is the Level of Pain *

Less than $10,000 $10,001 - $25,000 $25,001 - $40,000 $40,001 - $70,000 $70,001 - $100,000 Greater than $100,000 Prefer not to say

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Name *

First

Last

Email *

Comment *

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