Pain Questionnaire

QUESTIONNAIRE ON YOUR EXPERIENCE USING THE TECHNIQUES FOR REDUCTION AND «FREEDOM FROM PAIN AND ENHANCING INNER HEALING POWER»

 

NAME _______________________________ SEX ___________ AGE _______

COUNTRY ___________________________ PROFESSION ___________________

Email ___________________________________

 

Physical problem / pain/ discomfort ________________________________________

_________________________________________________________________

__________________________________________________________________

Where do you experience How long have you been pain or discomfort? experiencing this pain or discomfort?

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Once you have filled out at least a portion of this questionaire, please copy and past it into an email and send it to

webmaster@holisticharmony.com

RESULTS OF EMPLOYING THE TECHNIQUES  

 

1. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes.

If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

2. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

3. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

4. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

5. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

6. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

7. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

8. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

9. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

10. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

11. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

 

12. Date ________ time ______ Where did you employ it? ____________________

I employed technique NΤ. 2__ Breathing, NΤ. 3__ Relaxation, NΤ.4___ EFT

For the following pain / problem /discomfort __________________________________

I rated the initial pain (from 0 to 10) at ____ before the technique and___ after the technique.

I employed the technique for ______ minutes for ____ times.

Did the problem / pain / discomfort return. ___ No ____ Yes. If yes after how many hours? _______

Comments _______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

 

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