Message Coming in Blank

I created an entire form. However, everything is emailed correctly other than the the information that was filled out in the form itself. I know that I need to somehow title the form [your-message] however, I am not sure how or in which section I need to do that in. Any help would be greatly appreciated.

<h3><center>INVIGORATING CONSCIOUSNESS,LLC</center></h3>
<h3><center>HOLLISTIC HEALTH ASSESSMENT</center></h3>

<b>Important: This is a CONFIDENTIAL questionnaire to help us determine the best treatment plan for you. Please fill it out as completely as possible, even if you do not feel certain questions pertain to your present condition. Thank you. </b>

<label> Your Full Name (required)
   [text* your-name]</label>
<label> Email (required)
   [email* your-email]</label>
<label> Gender (required)
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="Female">Female</option>
    <option value="Male">Male</option>
    <option value="Other">Other</option>
</select>
<label> Marital Status (required)
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="Single">Single</option>
    <option value="Married">Married</option>
    <option value="With a significant other">With a significant other</option>
</select>
<label> Today's Date - mm/dd/yy (required)
    [date* date-011 date-format:mm/dd/yy placeholder "mm/dd/yy"]</label>

<label> Home Address (required)
  [text* text-013]</label>
<label> City (required)
  [text* text-014] </label>
<label> State (required)
<select>
<option value="" disabled selected>Select your State</option>
<option value="AL">AL</option>
<option value="AK">AK</option>
<option value="AZ">AZ</option>
<option value="AR">AR</option>
<option value="CA">CA</option>
<option value="CO">CO</option>
<option value="CT">CT</option>
<option value="DE">DE</option>
<option value="FL">FL</option>
<option value="GA">GA</option>
<option value="HI">HI</option>
<option value="ID">ID</option>
<option value="IL">IL</option>
<option value="IN">IN</option>
<option value="IA">IA</option>
<option value="KS">KS</option>
<option value="KY">KY</option>
<option value="LA">LA</option>
<option value="ME">ME</option>
<option value="MD">MD</option>
<option value="MA">MA</option>
<option value="MI">MI</option>
<option value="MN">MN</option>
<option value="MS">MS</option>
<option value="MO">MO</option>
<option value="MT">MT</option>
<option value="NE">NE</option>
<option value="NV">NV</option>
<option value="NH">NH</option>
<option value="NJ">NJ</option>
<option value="NM">NM</option>
<option value="NY">NY</option>
<option value="NC">NC</option>
<option value="ND">ND</option>
<option value="OH">OH</option>
<option value="OK">OK</option>
<option value="OR">OR</option>
<option value="PA">PA</option>
<option value="RI">RI</option>
<option value="SC">SC</option>
<option value="SD">SD</option>
<option value="TN">TN</option>
<option value="TX">TX</option>
<option value="UT">UT</option>
<option value="VT">VT</option>
<option value="VA">VA</option>
<option value="WA">WA</option>
<option value="WV">WV</option>
<option value="WI">WI</option>
<option value="WY">WY</option>
</select>
<label> Zip Code:
  [number your-telephone min:10000 max:9999 placeholder "Zip Code"]</label>
<label> Date of Birth - mm/dd/yy (required)
   [date* date-010 date-format:mm/dd/yy placeholder "mm/dd/yy"]</label>
<label> Age (required)
  [number number-009]</label>

<label> If under 18, person responsible for your account:
  [text your-name] </label>
<label> Work Phone:
 [tel tel-008]</label>
<label> Home Phone:
  [tel tel-007]</label>
<label> Cell Phone:
   [tel tel-006]</label>
 
<label> Are you a caregiver for dependents?
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> If yes, how many children?
   [number number-005]</label>
<label> If yes, how many adults?
   [number number-004]</label>

<label> Occupation:
  [text text-003]</label>
<label> Number of years in this type of work:
   [number number-015]</label>
<label> Retired: Number of years in retirement:
   [number number-002]</label>
<label> Occupation when in workforce (please fill out the previous line)
 [text your-name] </label>

<h5>Primary care physician:</h5> 
<label> Physician Name (required)
    [text text-001]</label>
<label> Physician Phone:
   [number your-telephone min:1000000000 max:9999999999 placeholder "XXX-XXX-XXXX"]</label>

Please select Insurance coverage (Note: we do not accept insurance at this time, but can provide you with a statement for submissions to your company.) 
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="None">None</option>
    <option value="Workers’ Comp">Workers’ Comp</option>
    <option value="Auto Injury Health">Auto Injury Health</option>
<option value="Insurance Company">Insurance Company</option>
</select>

<h5>Please indicate if any of the following pertain to you: (indicating “yes” does not make you ineligible for treatment, however, it may restrict some of your treatment modalities) </h5>
<label> <b>Hepatitis</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>HIV</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>High blood pressure</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>Seizures</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>Pacemaker</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>Blood-thinning meds</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select> 
<label> <b>Pregnancy</b> 
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
<label> <b>Surgically implanted joint/bone replacement or stabilizers</b>
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>
 Are you currently under the care of any other health care provider (physician, chiropractor, therapist, massage therapist, etc.)?
<select>
    <option value="" disabled selected>Select your option</option>
    <option value="No">No</option>
    <option value="Yes">Yes</option>
</select>

If yes, please provide the name and title of the practitioner(s), the condition being treated and the length of time you have been receiving this treatment: Practitioner Condition Length of treatment to present [textarea textarea-016]

Please list all past medical conditions for which you were hospitalized and/or received surgery (include the dates). [textarea textarea-017]

Current Health Concerns Please list your health concerns in order of priority:
[textarea textarea-018]

What do you believe is causing your most important health concerns? 
[textarea textarea-019]

<h5>Emergency Contact:</h5>
<label> Your Name (required)
    [text* text-020]</label>
<label> Contact Phone (required)
    [number your-telephone min:1000000000 max:9999999999 placeholder "XXX-XXX-XXXX"]</label>

<h5>How did you hear about us?</h5>
<b>Please choose one and write name</b> 
<label> Current patient:
  [text text-021]</label>
<label> Friend:
 [text text-022] </label>
 <label> Doctor:
  [text text-023] </label>
<label> Insurance:
  [text text-024] </label>
<label> Advertisement:
  [text text-025] </label>
<label> Other:
  [text text-026] </label>

INVIGORATING CONSCIOUSNESS 
RELEASE AND WAIVER OF LIABILITY, INDEMNITY AND MEDICAL RELEASE
THIS FORM MUST BE SIGNED BY ALL PARTICIPANTS. IF PARTICIPANT IS UNDER 18 YEARS OF AGE, FORM MUST BE SIGNED BY MINOR AND HIS/HER PARENT/GUARDIAN. 
IN CONSIDERATION of the undersigned Participant being permitted to voluntarily utilize Invigorating Consciousness, LLC facilities, equipment, programs and services, participant and, if applicable, Participant's undersigned Parent/Legal Guardian (individually and collectively referred to as "Participant") hereby:
 1. ACKNOWLEDGES, agrees and represents that Participant understands that Invigorating Consciousness, LLC activities involve certain risks for physical injury. Participant further acknowledges that physician evaluation is recommended before starting any physical activity program and realizes that it is Participant's responsibility to ensure that Participant's health status allows for safe exercise. Participant also acknowledges that there are potential risks of which may presently be unknown. Because of the dangers of participating in Invigorating Consciousness, LLC activities, Participant agrees to fully comply with Invigorating Consciousness, LLC applicable laws, policies, rules and regulations, and any supervisor’s instructions regarding participation with Invigorating Consciousness, LLC. Participant understands that Invigorating Consciousness, LLC does not insure participants in their activities, that any coverage shall be through personal insurance at Participant's expense and that Invigorating Consciousness, LLC has no responsibility or liability for injury resulting from Participant's utilization of Invigorating Consciousness, LLC or participation in the Invigorating Consciousness, LLC activities. 
2. FULLY RELEASES, WAIVES DISCHARGES AND COVENANTS NOT TO SUE Invigorating Consciousness, LLC, its Board, agents, employees or designees from any and all losses, causes of action, claims, damages or liability that Participant, Participant's spouse, child(ren), guests, legally authorized representative, assigns, successors and representatives may have that relates to, arises out of or is any way connected to Participant's use of Invigorating Consciousness, LLC or Participant's participation in Invigorating Consciousness, LLC activities. 
3. AGREES TO DEFEND INDEMNIFY AND HOLD HARMLESS Invigorating Consciousness, LLC, its Board, agents, employees or designees from and against any and all claims of any nature including all costs, expenses, and fees arising out of or resulting from Participant's actions during the Invigorating Consciousness, LLC activities or events. 
4. CONSENTS to receive emergency medical treatment which may be deemed advisable in the event of injury, accident or illness while at Invigorating Consciousness, LLC or while participating in Invigorating Consciousness, LLC activities. By signing below, Participant acknowledges that s/he has had the opportunity to review, discuss and ask questions about the terms and conditions contained herein. 
PARTICIPANT ACKNOWLEDGES THAT S/HE HAS READ THIS RELEASE AND WAIVER OF LIABILITY, UNDERSTANDS ITS TERMS, UNDERSTANDS THAT S/HE WILL BE GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE OR GUARANTEE BEING MADE. 

<label>Full Name of Participant:
[text* text-027]</label>
<label>Signature of Participant:
[signature* signature-028 cols:500]</label>
<label>Today's Date:
[date* date-029 date-format:mm/dd/yy] </label>

<b>MINOR INFORMATION: </b>
<label>Name of Parent/Legal Guardian: 
[text text-030]</label>
<label>Age (If A Minor)
[number number-031]</label>
<label>Signature of Parent/Legal Guardian:
[signature signature-032 cols:500]</label>

[submit "Send"]

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