Energy Map Assessment Application

Hi! I'm Dr. Jenny Tufenkian, and thank you for being willing to invest the time in yourself to book a call. I am looking forward to meeting with you soon! Please complete this prior to your Energy Mapping call. This gives a jumping point for the assessment and helps me determine if I am the best person to help you or not.

Name (First and Last Name) *

Email *

What are you most interested in? Please tick ALL that apply. *

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How did you come across our energy assessment form? Was it through; *

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On a scale of 1-10, how would you rate your physical energy level? (10 being highest energy) *

On a scale of 1-10, how would you rate your mental clarity/ability to focus and create? (10 being highest energy) *

On a scale of 1-10, how would you rate your emotional well-being? (10 being highest energy) *

Tell us about your physical symptoms and how they affect your life. *

What do you most want to experience instead, physically, mentally, and emotionally? What are your top health goals? *

What’s getting in the way of you reaching your health goals? (Be as specific and honest as possible.) *

What kind of health approaches have you tried in the past? *

Who in your immediate social circle will support you in your efforts 100 percent? Who are the ‘cheerleaders’ (or quiet loving supporters) in your life? *

What would you be able to accomplish, if you were feeling at your best? *

Anything else you would like to share? *

How did you hear about Dr. Jenny? *

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Website

Podcast

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Other

What Timezone are you in? *

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Alaska zones

Central

Mountain

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Phone *

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Energy Map Assessment Application

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