Health Waiver | SIMIN LIANG

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Health Waiver

Please take a moment to fill out the form.

First Name

Relationship

Last Name

Birthday * required

Email

Code

Phone

Select an Address

Emergencay Contact

Emergency Contact Telephone

Doctor's name

Last Check up

Doctoer's Address

Medications being taken

Health Problems (past&current)

Choose the challenges you are facing * Required

Addictions

Smoking

Drugs

Gambling

Compulisve Behaviour

Anxiety

Depression

Sadness

Stress

Fears

Phobias

Panic Attacks

Guilt

Relaxation

Eating Problems

Food/Diet Weight

Problems Anorexia

Bulima

Exercise

Interview

Money Block

Skills Nerves

Public Speaking

Concentration

Exams

Memory

Driving

Sexual Problems

Fertility

IVF

Conception

Pregancy

Birth

Pain Control

Hearing

Sight/Vision

Mobility

Skin Problems

Hair Growth

Relationship

Childhood Problems

Sleep Porblems

PMDD

Others

Describe your dream day and life wihtout any problems

Your Signature

Thanks for submitting!

©2025 by Transformational Therapist Simin

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