Name
*
First Name
Last Name
Date
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Date of Birth
*
Place of Birth
*
Cell Number
*
(###)
###
####
Email
*
Gender
*
Marital Status
*
Checkbox
What are the major concerns in your life today?
*
What would you like to have more of in your life?
*
Emergency Contact Name
*
Emergency Contact Number
*
(###)
###
####
Relation to Client:
Number of organs removed:
*
Number of synthetic drugs used currently:
*
Number of times you smoke a day:
*
Number of steroid-type drugs you've used in the past year:
*
Number of alcoholic drinks per day:
*
Number of street drugs used each month:
*
Number of caffeine products per day:
*
Number of silver fillings in your mouth:
*
Number of all known allergies:
*
Number of unsolved emotional factors:
*
Amount of fat in diet:
*
Number of sugar-type products per day:
*
Number of exercise sessions per day:
*
Number of toxic exposures in the past year:
*
Number of major injuries in the past:
*
Number of major infections in the past:
*
Number of glasses of water per day:
*
How many pounds overweight are you?
*
I am responsible for my body (1-10):
*
Personal stress (1-10):
*
Prior Conditions
*
Please check if you have any of the following:
Other Prior Conditions:
Diabetes?
*
If so, who?
Hypertension?
*
If so, who?
Stroke?
*
If so, who?
Alcohol Problems?
*
If so, who?
Mental/Emotional Problems?
*
If so, who?
Heart Disease?
*
If so, who?
Hepatitis/Liver Disease?
*
If so, who?
Cancer?
If so, who?
Congenital Problems?
*
If so, who?
Other?
If so, what and who?
Describe any concerns you may have, and your objectives in seeking wellness services here:
*
I understand that the attending practitioners are not allopathic doctors (MDs) and do not portray themselves to be, but are providing biofeedback and wellness services. I understand that the services provided identify energetic imbalances. Procedures utilized include stress reduction protocols, nutritional wellness consultation, and biofeedback. I fully understand that the attending practitioners do not offer allopathic drugs, surgery, chemical stimulants, or any other conventional treatments. In addition, I understand that the attending practitioners do not diagnose, treat, or otherwise prescribe for any, including my specific, diseases, conditions, or illnesses, or perform any act that would constitute the practice of medicine for which a license is required. I have solicited the attending practitioners’ services in good faith, exercising my free will and following the dictates of my own conscience which allows me to select what I understand is most beneficial to my health. I am fully aware and release the practitioner to do biofeedback testing, wellness consultation, and other stress reduction protocols. By signing below, I acknowledge that I have read and understand all parts of this waiver, that I have had the opportunity to ask any questions with regard to the described procedures, and that I hereby affirm: I am not here for medical diagnostic or treatment procedures, and I am here on this any subsequent visit solely on my own behalf.
*
Prospective client, please sign if you agree to the above statement. If you are under 18, please have your parent/legal guardian sign on your behalf.
Date of Signature
*
MM
DD
YYYY
