Medical Astrology Reading

Full Name 🌕

Please enter your full name.

Email Address 🌕

Please enter a valid email address.

Gender 🌕

Please enter your gender.

Where do you live currently? 🌕

City, state & country

Please enter where you live.

Occupation (if applicable)

Relationship status

Who do you live with?

Select all that apply

Partner Roommates Family Solo

Do you have children?

Yes No Not yet, but actively trying

If so — how many, and what are their names and ages?

Who referred you / how did you find me?

How much astrology knowledge do you have? 🌕

You don't need any — I just like to know

Please select your astrology knowledge level.

What would you like the appointment to be about? 🌕

Be as specific as possible

Please describe what the appointment should be about.

If inquiring about specific ailments — do you have dates these issues started? 🌕

Be as specific as possible

Please provide dates when issues started (or type N/A if not applicable).

Any other issues you'd like addressed? 🌕

Be as specific as possible

Please answer this question (or type N/A if not applicable).

How many hours of sleep do you get on average?

What time do you generally go to bed and wake up?

Do you wake up tired or refreshed?

Please explain

Do you have trouble sleeping?

Falling asleep, staying asleep, waking early, etc.

Average energy level

1 = super low · 5 = neutral · 10 = bouncing off walls

5

1510

Average stress level

1 = at peace · 5 = depends · 10 = anxious mess

5

1510

Do you exercise?

If so, what type and how often?

Prescription medicines you take (if any)

Please list each one and what you're taking it for

Supplements you take (if any)

Please list each one and what you're taking it for

Herbs you take (if any)

Please list each one and what you’re taking it for

Are you on birth control?

Pill, IUD, implant, etc.

What do you expect to achieve by working together? 🌕

Please describe what you expect to achieve.

How committed are you to making the necessary changes? 🌕

1 = not at all · 10 = 100% committed

7

1510

Please select your commitment level.

Anything else you'd like me to know, or any questions you have? 🌕

Please answer this question (or type N/A if not applicable).

Medical Astrology Reading
Pre-Questionnaire

Thank you for completing the intake form.

Medical Astrology ReadingPre-Questionnaire

Thank you for completing the intake form.

Medical Astrology Reading
Pre-Questionnaire