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Questionnaire for Vibrational Health Assessment & Analysis (VHAA)

Full Name  
Date of birth    
Place of birth    
Email    
Contact Tel.    
Country  
Date of Reg.    
   
 Allergies    
Any allergic reaction    
Have you had any accidents? When
Have you had any operation? When
Part of body
Outcome
Are you on any drug / medication presently? If yes what is the result
Please specify what kind Quantity and frequency
 

Have you ever had or do you presently have any of the following ailments? (If yes explain

Headaches
Coughs
Asthma
Digestive problem
Diarrhea
Constipation
Sugar problem
High/low blood pressure
Blood problems (anaemia)
Urinary problems
Sexual impotence/Frigidity
Menstrual problems
Pregnancy problems
Nervousness
Constant Tiredness
       
 
Payment Details
 
   
Transfer money details