Information Form 2

Today's Date:

What Is Your Full Name?

What is your age?

Your Email Address

This questionnaire has been designed so that we can both review your past history and other factors in your life that affect your well being. The questionnaire makes it possible for me to be more thorough within the constraints of remote dialogue and interaction. It is fairly long and detailed. Some of this information is already in your Information Form 1, but I am going to ask you to repeat some of it here, to be sure I obtain your complete personal picture. Some questions are very personal - if you do not wish to answer these, please skip over them. These questions represent some of the more common subjects addressed by previous protocol participants, but is not intended to be an exhaustive, complete list. All information collected will be kept strictly confidential. If I require additional information I will send you an email and/or possibly schedule a phone call. Thank you for your participation in the Mainstreet Miracle Manifestation Protocol.

Medical History

Have you had any past medical issues or illnesses?
AccidentsBroken BonesOther Serious InjuryAnemiaBleeding ProblemsLung ProblemsPneumoniaEmphysemaHeart ProblemsGland ProblemsDiabetesHigh Blood PressureThyroid TroubleGastrointestinal ProblemsUlcersDiarrheaConstipationHigh CholesterolMental ProblemsDepressionAnxietyAllergiesAsthmaHay feverCancerLiver ProblemsKidney ProblemsSkin DiseasePhysical PainHeadachesSkin DiseaseTuberculosisSexually Transmitted DiseasesNeurologicSeizuresPinched Nerves
Any Medical Issues or Illnesses not covered above?

Have you had any past surgeries? Please list approximate dates and procedures.

Family History

Where you adopted? YesNoUnknown

Please list the status of your current family members. Check all that apply.

Mother LivingDeceasedUnknown

Father LivingDeceasedUnknown

Brothers LivingDeceasedUnknown

Sisters LivingDeceasedUnknown

Husband/Wife LivingDeceasedUnknown

Children LivingDeceasedUnknown

Adopted Children LivingDeceasedNone

Please provide any additional details here.

Has anyone in your family had trouble with the following:
(Include mother(M), father(F), sister(S), brother(B), grandmother (GM), grandfather(GF), aunts(A), uncles(U)) If multiple, please select the first known or earliest.
Alcoholism or drug abuse N/AMFSBGMGFAU
Blood clots in legs or chest N/AMFSBGMGFAU
Depression or mental illness N/AMFSBGMGFAU
Diabetes N/AMFSBGMGFAU
Cancer N/AMFSBGMGFAU
Heart attack before age 50 N/AMFSBGMGFAU
High blood pressure N/AMFSBGMGFAU
High Cholesterol N/AMFSBGMGFAU
Stroke N/AMFSBGMGFAU
Osteoporosis N/AMFSBGMGFAU
Mental retardation N/AMFSBGMGFAU
Liver disease N/AMFSBGMGFAU
Bleeding problems N/AMFSBGMGFAU
Congenital Abnormalities N/AMFSBGMGFAU
Please provide any additional details here.

Social History

Where were you born?

Where did you grow up?

What is your current marital status?
SingleMarriedDivorcedOther

If not married or divorced, have you ever been in a committed relationscip?
YesNo

Do you have children?
YesNo
Son(s)Daughter(s)Both son(s) and daughter(s)

Are you sexually active?
YesNo

Does your level of sexual activity match your interest and desire?
YesNo

What is the highest level of education that you have completed?
Grade schoolHigh schoolTrade schoolCollegeOther

Are you currently employed? YesNo

Occupation

EmployedUnemployedRetired

Do you feel stressed at work? YesNo
If yes, please describe the conditions of the stress.

Do you exercise? Please select all that apply.
YesNo1 - 3 times per week3 + times per week

What kind of exercise do you usually do?

How long do you exercise?

Is there a particular spiritual practice or belief system that is meaningful to you?
YesNo
If yes, please describe the spiritual practice or belief system.

Social Support

How do you deal with conflict in your family?

How do you deal with conflict among your friends and peers?

Who provides you with emotional support(family, close friend, religious advisor, other) when needed?

How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired?

Sitting and reading 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Watching TV 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Sitting, inactive in a public place 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
As a passenger in a car 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Lying down to rest in the afternoon 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Sitting and talking to someone 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing
Sitting quietly after lunch without alcohol 0 = would never doze1 = slight chance of dozing2 = moderate chance of dozing3 = high chance of dozing

Now that there has been a little time since you completed Information Form 1, and answered more questions about yourself, what do you want to manifest?

Why do you want to manifest this?

Imagine you had a magic wand and could change three things about yourself and your life. What would they be?

By signing below, I attest that the information provided is truthful and accurate. Please write your signature in the area below.

Clear

When you have completed all entries on the form and signed in the space provided above, you must click the SUBMIT button to save your information, which will allow me to access and review it.