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click here for the questionnaire as a pdf file for printing on US letter paper (to fill out when you use the techniques.) click here for the instructions as a pdf file for printing on US letter paper. QUESTIONNAIRE ON YOUR EXPERIENCE USING THE CD FOR REDUCTION AND «FREEDOM FROM PAIN AND ENHANCING INNER HEALING POWER»NAME _______________________________ SEX ___________ AGE _______ STATE ___________________________ PROFESSION ___________________ Email ___________________________________ Physical problem / pain/ discomfort ________________________________________ _________________________________________________________________ __________________________________________________________________ Where do you experience How long have you been pain or discomfort? experiencing this pain or discomfort? ___________________________________________________________________ _________________________________________________________________________________________________________________________________________________________________________________________________________ RESULTS OF EMPLOYING THE TECHNIQUES ON THE CD1. Date ________ time ______ Where did you employ it? ____________________ I employed technique NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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 NÔ. 2__ Breathing, NÔ. 3__ Relaxation, NÔ.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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