Decode Me - Symptoms -Questionnaire Name * First Name Last Name Date of Birth MM DD YYYY Email * What brings you here? What are you hoping to discover from this decoding? What are the 3 main physical symptoms or conditions you’re currently experiencing? Chronic fatigue? Hormonal imbalances? Digestive issues? Pain? Weight changes? Please list. When did these symptoms start? Did anything significant happen around that time (emotionally, physically, relationally)? What medical diagnosis (if any) have you been given related to your symptoms? If you’re undiagnosed, write “none” How would you describe your current emotional state, in a word or a sentence? Do you feel there’s an emotional root or trauma connected to your symptoms? If yes, describe it. Are you dealing with stress, grief, conflict, or burnout? Please explain anything relevant. Do you have a history of people-pleasing, over-responsibility, or suppressed emotions? What do YOU intuitively feel your body is trying to tell you? Even if it sounds wild, write it. Are there any ancestral patterns, recurring family illnesses, or emotional stories you feel might be linked to your symptoms? What healing modalities have you tried so far (medical, holistic, energetic)? What helped or didn’t help? Anything else I should know to better support your energetic decoding? Please read and acknowledge the following before submitting your information: I understand that by purchasing the "Decode Me" service and submitting my medical test results and health history, I am consenting for Severine Baron to view and interpret this information through the lens of energy work, emotional insight, and metaphysical understanding. I understand that this is not medical advice, does not replace a licensed healthcare provider, and is for informational and transformational purposes only. I acknowledge that Severine Baron is not diagnosing, treating, or prescribing. I take full responsibility for my own health decisions and agree to consult with a licensed physician for any medical concerns. I understand my privacy is respected and that all submitted information will be held in confidence. I agree to the terms above. I give consent for Severine Baron to review and interpret my symptoms. Thank you for submitting your info.Your file will be reviewed and Sev will send back a report in the next 3-5 days.
