Mind-Body MEDICINE Assessment Form

We want to acknowledge your courage and willingness in reaching out for help. By answering the questions in this form as fully as you can you’ve taken an important step towards getting that help! When you get to the bottom of each page, click NEXT until you reach the end. You will be asked to sign before you can submit. Thank you! ** Allow about 5-10 minutes ** Make sure to finish in one sitting, and SUBMIT at the end, or your info may be lost. Please fill in all of the information below with as much detail as you can and to the best of your ability so that you may recieve the best care possible!*Note: I have no way of manipulating the scan based on your info as it communcates with your body using bio-frequencies and electriomagnetic signals from your OWN voice. More than 120,000 vibrational frequencies have been isolated, identified & catalogued by AO Scan. The technology reads, interprets energy, vibration and resonance signals. Every cell is made of energy and the signals measure and guide the body back to homeostasis. "When your mind, body, & spirit are homeostasis, you will find your golden OASIS!" -Krista Bigler You will be asked to sign before you can submit. Thank you! Please hydrate as well as possible before your scan and keep us updated on how you are feeing afterward.*This information will be kept strictly confidential. Our personal information is collected for the purpose of providing care and for administrative purposes. It will not be disclosed for other purposes without your consent.

Name*

First NameLast Name

Birth Date*

MonthDayYear

Phone Number*

Area CodePhone Number

Email*

example@example.com

Address*

Street Address

Street Address Line 2

CityState / Province

What Are You Hoping to Gain From This Session? *

What Brings You To Try This Modality At This Time?*

Are You Ready to Make a MASSIVE TRANSFORMATION in Your Life? (SCALE 1-10)*

Are You Willing to Commit to Listen to Your Custom Harmonics At Least 2x Per Day?:*

Are You Taking Any Suppliments? If Yes, What Kind and What Are They Used For?*

Please specify dose and usage

My Biggest Source(s) of Stress/Anxiety or Depression Are:*

I Would Rate my Current Stress/Anxiety on a Scale of 0-10 (10 being high)*

if 0 don't click any stars

I Would Rate my Current Depression on a Scale of 0-10 (10 being high)*

if 0 don't click any stars

Please List Your Current Health Concerns...*

I Would Rate my Current Health Concerns on a Scale of 0-10 (10 being high)*

if 0 don't click any stars

Which Things Are You Interested In? Select All That Might Apply

Does Your Significant Other Support You?*

YesNoSometimesNot Applicable

Could He/She Attend the Session With You?

YesNoMaybeNot Applicable

Please Provide Any Further Details About Trauma or Health History that You Feel May Be Relevant.

Tell Us About Your Strengths, Hobbies, Interests. What Do You Like to do For Fun and Relaxation?

What is Your Current Profession?*

I Envision My Relationship with Authentic Healing with Krista & Mind-Body Team as...*

What Are Your Current Top 3 Goals?

Why Do You Believe You Have NOT Reached Your Goal?

What Day/Times Work Best for You?*

Please upload here, Instant Message me a 12 second voice clip or leave a voicemail stating your name, "I am _______ " and then count to 10. If you choose voicemail, please send a text right before indicating you will be calling to leave a voice message. Your voice is your unique profile and I will play this clip to my AO Scan device. Inner Voice will identify your Emotional Imbalances from the tones in your voice & create healing harmonics with frequencies (4 MP3's) for you to balance your emotional state. The tones play for approximately 12 minutes. The more you listen, the more you will benefit like pealing layers of an onion. You will also recieve a 4 page report with some associated physical issues and suggestions. These bring up and release underlying emotions causing imbalances in your mental and physical health.

Browse Files

My Voice Clip was...*

Please Indicate Best Social Media Platform For You & Add Handle*

Instagram Handle blanks
Facebook Handle blank

Linked-In Handle blanks
Tik-tok Handle blank

Twitter Handle blanks
Pinterest Handle blank

Today's Date*

YearMonthDay

Signature (hold/click and sign with cursor)*

Clear

Mind-Body-Spirit Assessment Form

ABOUT YOU

Client Details

Let us learn more about your concerns

Stress/Anxiety & Depression Hx

Support & Resources

My Mind-Body Goals

My signature below affirms that I have answered the above as truthfully and completely as possible: