Discovery Call Breast Implant Illness Analysis Name(Required) First Name Last Name Date of Birth(Required) MM slash DD slash YYYY Email Address(Required) Gender(Required) Female Do you believe you have Breast Implant Illness?(Required) Yes No What is your main symptom and how often does it bother you?(Required) How long have you been dealing with symptoms of Breast Implant Illness?(Required) Please explain your experience and your symptoms in as much detail as possible.(Required) What are your physical symptoms and how do they affect your life?(Required) What are your mental and emotional symptoms and how do they affect your life?(Required) On a scale of 1-10 (1=none, 10=most possible) how would you rate your physical energy levels?(Required) On a scale of 1-10 (1=least, 10=most) how would you rate your mental clarity/ability to focus and create?(Required) On a scale of 1-10 (1=least, 10=most ) how would you rate your emotional well-being?(Required) What do you wish you could change about your life and how all of this affects you every day?(Required) If you could wave a magic wand and be 100% healed today, what would you be able to accomplish, if you were feeling your best?(Required) What or who could keep you from participating and fully committing to your custom healing + detoxification progam? ( Please select all that apply )(Required) children partner time self money fear job resources nothing Select All In addition to the above, what’s keeping you reaching your health goals (be as specific and honest as possible)?(Required) What kinds of approaches have you tried in the past that have not worked?(Required) How does this affect your life or what does it prevent you from doing?(Required) Have you worked with a health practitioner or a doctor in the past, and if so, how did that go?(Required) What would you expect to achieve working with me?(Required) Since working with me would be an opt-in model of self-care that will require money, time, and effort to see change, on a scale of 1-10, how committed are you to putting in the work to see results, and why?(Required) Is there anything else you'd like to share with me about your experience before our meeting? Thank you for taking the time to share your journey with Breast Implant Illness. Please remember to schedule your FREE Analysis Call after you hit the Submit button below. Chat Soon! ♥️ Andi
