Bioenergetic Scan · Pre-Session Intake

Before we read your energy, tell us your story

Your scan shows the frequencies — this form gives them context. Take a quiet moment, answer honestly, and know that everything you share stays confidential.

01 · About You

The basics

So we can prepare your session and reach you with your results.

Full name *

Date of birthFor your energetic blueprint (Human Design & astrology insights)

Time of birthAs exact as you know it — check your birth certificate if possible. This makes your Human Design chart precise.

Place of birthCity & country

Email *

Phone / WhatsApp

Have you had a bioenergetic scan before?

02 · Your Why

What brought you to the scan

Your intention shapes how we read your results.

What intrigued you about the bioenergetic scan? *

What are you most hoping to learn or receive from this experience?

If there is one concern at the top of your mind right now, what is it? *

03 · Physical Body

How your body is feeling

Rate where you are today — there are no wrong answers, only honest ones.

Daily energy level

Running on emptyFully charged

Sleep quality

RestlessDeeply restorative

Is your body currently experiencing any of the following?

Anything you'd like to share about your physical health?Diagnoses, injuries, recent changes — whatever feels relevant

Current medications & supplements

04 · Mind & Heart

Your mental & emotional landscape

The heart and nervous system speak loudly in a scan — this helps us hear what they're saying.

Stress level lately

Calm watersConstant storm

Mental clarity & focus

FoggyCrystal clear

Which of these have been present for you lately?

How are you doing emotionally, in your own words? *

Are you moving through any significant life transitions right now?Relationships, work, family, loss, relocation, motherhood — anything shifting

05 · Daily Rhythms

Your lifestyle & habits

Your daily rhythms are the foundation of your cellular energy.

How would you describe your hydration?

How often does your body move?Walks, dance, workouts, yoga — all movement counts

How would you describe the way you're nourishing yourself lately?

06 · Your Intentions

Where you're seeking support

This helps us focus your session on what matters most to you.

Which areas are calling for the most support?Choose up to three

Imagine yourself six months from now, fully lit up. What does that version of you feel like?

Is there anything else you'd like Diana to know before your scan?

This questionnaire supports your bioenergetic wellness session and is not a substitute for medical care. Your responses are confidential.