Client Full Legal Name:       Title:

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To maintain confidentiality, the email above is where your suggestions will be emailed.

Last Virtual Research Contract Date (from this research service provider):

RESEARCH FOCUS: Here, specify the focus of the research requesting. If left blank, these factors may not be considered for the findings:

Age Group:     Gender:      Weight:     Height: 

Blood Pressure:     Recent Blood Work (Results):

Known Environmental Allergies:   Known Topical/Skin Allergies:

Current Medications Intake (Dose/Frequency):

Current Supplement Intake (Dose/Frequency):

Year Range PTSD Diagnosed by a Licensed Psychiatrist/MD): 

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Did you follow the suggestions based on the last research conducted by this Firm? Explain.

Again, thank you for your service. Since our last virtual session, how do you feel about: (a) Educators (Academic, Mentors) in Your Life: (b) Your Career Choices:

Symptom 1 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 2 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 3 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 4 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 5 ~ Physical ~ Stated Last Virtual Session (Explain~Same, Improved, or Worsen/Describe~Location, Duration, Frequency):

Symptom 6 ~ New ~ Describe~Location, Duration, Frequency:

By pressing the submit button, I agree to the terms indicated on the PTSD Symptoms ~ Followup webpage (Brigette's Natural Healthcare Advisory and Research Firm~hereby known as the "Firm") and with the payment terms. I also certify that all the information presented in this submission is true, and I consent to the use of disclosure of the information submitted for healthcare advisory services. I acknowledge that the email address provided is secure, and that the Firm cannot and will not be held liable for any breach in the email system or of the information or misinformation transmitted using this electronic platform. I further understand the Firm cannot or will not be held legally liable for any symptoms (prior, current, future) to include symptoms that have been indicated or omitted in this transmission. This Service Agreement and any dispute there under shall be governed by the laws of the State of Georgia, USA.