Medical Questionnaire

Please fill out the following form to help us understand your physical condition.

Have you been hospitalized in the last 12 months?
Are you currently suffering from a medical condition, illness, or injury?
©Diamond Hypnotherapy 2019

Stephanie Newton is a certified practitioner of Havening Techniques. Havening Techniques is a registered trade mark of Ronald Ruden, 15 East 91st Street, New York. www.havening.org