Initial testing and treatments are $195.00
|Address||Fax:||Any Inherited Diseases in your family? Yes No|
|City & Postal Code:||E-mail:|
|Date of Birth Time of Birth||Place of Birth
On a scale of 1 - 10 How much negativity do you have?
|List of Current Medications, Prescriptions & Supplements:|
|Main Complaint||Secondary Complaint||Other Concerns|
Trouble falling asleep?
Wakes during sleep?
How many times a night?
one a day
two a day
three or more a day
Stomach Pain? Gas? Bloating?
Acid Reflux? Heartburn? Other?
||11. What is your personal stress level on a scale of 1 - 10 (10 being high)|
|2. Number of Prescription Medications that you are currently taking or recently taken||12. How many sugar products a day do you have (sugar in tea/coffee, cookies, pop etc)|
|3. Number of cigarettes smoked per day||13. How many exercise sessions per week of 20 min. or more do you get (don't count working)|
|4. Steroid drugs (sprays, inhalers or creams) used in the last year||14. Alcohol consumption per day on average|
|5. Number of silver dental fillings, root canals, posts, crowns, false teeth, gold or any metals||15. Coffee/tea/caffeine/ chocolate per day do you have on average|
|6. Number of Over The Counter drugs or street drugs used in the past few years||16. Xrays/flying/insecticides/chemical exposures/dental xrays/etc in the past year|
|7. Number of allergies: food, drug or environmental||17. Major injuries in your entire life. Surgeries, car accidents, concussions, broken bones, any ER visit!|
|8. Unresolved emotional issues over your life time (family, grief, work, emotional etc)||18. How many times in your entire life have you been on antibiotics (IV, caps, tabs, injections)|
|9. How responsible are you for your own health on a scale of 1 - 10||19. How many glasses of water or natural fruit juice per day do you have|
|10. How much fat is in your diet
2= ideal 4= average 5 = more
|20. How many pounds overweight do you feel like you are?|
This is to acknowledge that I have been informed about the treatment being offered and I fully understand and accept that this treatment is being performed by a Internationally Licensed Biofeedback Technician.