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 Somatic Inventory Survey Instructions
 
Please complete the survey below to the best of your ability. If you have additional family members participating, please have them do one as well, even if it's an infant - everyone is a control group of one up in here! OK? When you submit the form, you'll receive an e-mail directing you to a page that has 4 self-tests I use to get a sense of your 'vital capacity' baseline. You can do all of this for FREE FREE FREE. Once you complete these steps, I need you to e-mail me your data along with a current photo of you that has you directly facing the camera. When I receive that, you'll get an invoice from PayPal for your initial 30-day program. When that invoice is paid, your Docta On Demand program will be activated. You'll be notified by e-mail when your 'wave' will begin. If you have any additional questions or concerns about the program or the registration process, feel free to e-mail me at nakedsoma@gmail.com - I'll get back to you within one business day including weekends (sometimes faster!)

I'll also tell you if you're not quite ready to begin but you took the time to gather the data, your information will be valid for 90 days so please just tell me that you're going to put your program on hold and I'll note that in the records here. If you have a financial challenge delaying you, bring that to my attention ASAP. There's nothing worse than letting money get in the way of your vitality. I won't let that happen on my end. Fair enough? ;)

With that, I'll say thank you for participating and I look forward to getting you some relief & renewel pronto!    

 

* Required fields
Name *
E-mail Address *
Age *
Occupation *
What's your burning issue that you want help with? Relax, if you can't finish here there's extra space to add stuff at the end! *
Finish this sentence - "I'll know if this program helped me if..." *
Have you ever experienced bodywork or any other somatic modality? *
If yes, what's the contact information for your current practitioner(s)
Please give me a local recommendation for a practitioner
Do you have a mainstream physician? *
If yes, what's the contact information for your current mainstream physician(s)
Were you ever told about the role of attention in human health and quality of life? *
List any other recurring injuries, infections, etc *
Any surgeries? (please provide dates and be specific) If not, say so! *
What are the average # of hours you work per week? *
What are the average # of hours you sleep per week?
What are the average # of hours you exercise per week? *
Please evaluate your current physical status *
Please evaluate your current mental/emotional status *
Open Space - Add to your comments above or give me any information you feel has not been covered
I certify that the above information is accurate and complete to my knowledge *
I share this with an understanding of confidentiality and reserve my right to update it *

I have read and agree to the Privacy Policy *

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