Name:
Address:
City:
Province/State:
Country:
Postal/Zip Code:
Home Phone:
Cell Phone:
Personal email address:
Birth Date (dd/mm/yy):
Time of birth (if known):
Birth Place (City/Country):
Gender:
Are you?
Marital Status:
Occupation:
Name of partner or spouse:
Partner/spouse date of birth (dd/mm/yy):
Employer:
Work address:
Work phone:
Child #1:
Birth Date (dd/mm/yy):
Child #2:
Birth Date (dd/mm/yy):
Child #3:
Birth Date (dd/mm/yy):
Child #4:
Birth Date (dd/mm/yy):
Child #5:
Birth Date (dd/mm/yy):
Emergency contact:
Emergency telephone:
Emergency cell phone:
No. of organs removed:
No. of teeth removed:
No. of prescription drugs used currently:
No. of steroid drugs used in past year:
No. of street drugs used each month:
No. of cigarettes per day:
No. of metal fillings:
No. of known allergies:
No. of unresolved mental-health issues (greed, resentment, anger, etc.):
I am responsible for my body:
Percentage of fat in your diet (average is 45%):
Personal stress level (none=0, max=10):
No. of sugar products per day:
No. of 20 min.+ exercise sessions per week:
No. of alcoholic beverages per day:
No. of caffeine products per day (coffee, tea, chocolate, cola):
No. of extreme toxic exposures per year (chemo, radiation etc.):
No. of major traumatic injuries in your life (mental, physical etc.):
No. of major infections in your lifetime:
No. of 8 oz. glasses of water per day:
No. of pounds you feel overweight:
FAMILY HISTORY: Please indicate if any family members have had any of the following medical issues and if so what is their relationship to you?
Diabetes:
Hypertension (high blood pressure):
Stroke:
Alcohol & Drugs:
Mental/Emotional:
Heart Disease:
Hepatitis/Liver Disease:
Cancer:
Congenital disease or condition:
Other:
Please indicate if you have or have had any of the following (check all that apply):
Other:
Describe any concerns and your objectives in seeking wellness services:
Were you referred by someone?
I understand Jeni Shaw or the attending Biofeedback specialist are not medical doctors nor do they portray themselves to be, but are providing Biofeedback services only.
I fully understand that the biofeedback programs are utilized for stress reduction, relaxation and training only.
I understand that Jeni Shaw or the attending Biofeedback specialists do not offer allopathic drugs, surgery, chemical stimulants or any other conventional medical treatments.
In using the Biofeedback programs, Jeni Shaw or attending Biofeedback specialists do not diagnose, treat, cure or otherwise prescribe for my disease, condition or illness.
I have solicited Jeni Shaw’s or attending Biofeedback specialists 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 at this present time.
I am fully aware and release Jeni Shaw or the attending Biofeedback specialists to run Biofeedback stress reduction programs on me and that all information disclosed as well as my identity will be held in the strictest confidence except as specifically required by law.
By including my name and checking "yes" to the "I consent" option below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask questions with regard to the described programs. I hereby confirm
I am not here for medical diagnostic or treatment procedures and am here on this and any subsequent visits of my own free accord. I presently seek Biofeedback and or any other programs within the scope of Jeni Shaw or the attending Biofeedback specialists for stress reduction, relaxation and awareness training.
