Name
Street Address
Address (cont.)
City
State
Zip/Postal Code
Work Phone
Home Phone
E-mail

Male    Female    Pregnant

Do you have a Pacemaker?

Yes No

Date of Birth

Place of Birth

 

Number of organs removed		Personal stress level on a scale of 1-10
Number of synthetic drugs used currently		Number of sugar type products per day
Number of times you smoke in a day		Number of exercise sessions in a week (at least 20 min. not including work activities)
Number of steroid type drugs used in the past year (birth control pills, asthma inhalants)		Number of alcoholic drinks per day
Number of street drugs used each month		Number of caffeine products per day
Number of known allergies		Number of toxic exposures (radiation, chemicals, insecticides, etc)
Number of unresolved emotional factors (anger, depression, anxiety, grief, etc)		Number of major injuries in the past
I am responsible for my body	disagree stronglydisagreeneutralagreeagree strongly	Number of major infections in the past
Number of amalgam fillings currently		Number of glasses of water per day
% of fat in diet (Normal diet is 40%)		How many pounds overweight do you feel you are?

Please check any of the following that you currently have or have had in the past:

Describe any concerns and your objectives in seeking wellness services:

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, we do not diagnose, treat or otherwise prescribe for my disease, conditions or illness, 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 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 and any subsequent visit solely on my own behalf.

Signature             Date