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Bioresonance Client Form
Bioresonance Client Form - Please Complete Entire Form
Name
Street Address
City
Postal/Zip Code
Country
Home Phone
Cell Phone
Personal Email Address
Birth Date (dd/mm/yy)
Time of Birth (if known)
Birth Place (City & Country)
Gender
Male
Female
Are You Pregnant?
Yes
No
Are you Nursing?
Yes
No
Marital Status
Single
Married
Divorced
Separated
Widowed
Name of Partner/Spouse
Partner/Spouse Date of Birth (dd/mm/yy)
Occupation
Employer
Work Address
Work Phone Number
Child #1 Name & Birth Date (dd/mm/yy)
Child #2 Name & Birth Date (dd/mm/yy)
Child #3 Name & Birth Date (dd/mm/yy)
Child #4 Name & Birth Date (dd/mm/yy)
Child #5 Name & Birth Date (dd/mm/yy)
Emergency Contact Name
Emergency Telephone
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 in Past Year
No. of Street Drugs Used in Each Month
No. of Cigarettes / Day
No. of Metal Fillings
No. of Known Allergies
No. of Unresolved Mental-health Issues (greed, resentment, anger, etc.)
Percentage of Fat in Your Diet (average is 45%)
Personal Stress Level (none=0, max=10)
0
1
2
3
4
5
6
7
8
9
10
No. of Sugar Products Per Day
No. of 20 min.+ Exercise Sessions/Week
No. of Alcoholic Beverages per Day
No. of Caffeine Products per Day (coffee, tea, cola, chocolate)
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
Alcoholism
Drug Addiction
Mental / Emotional Illness
Heart Disease
Hepatitis / Liver Disease
Cancer
Congenital Disease / Condition
Other
Indicate if you have or have had any of the following (check all that apply).
AIDS/ HIV
Alcoholism
Allergy Shots
Anemia
Anorexia
Appendicitis
Arthritis
Asthma
Bleeding Disorder
Breast Lumps
Bronchitis
Bulimia
Cancer
Cataracts
Chemical Dependency
Chicken Pox
Depression
Diabetes
Emphysema
Epilepsy
Fractures
Glaucoma
Gout
Heart disease
Hepatitis
Hernia
Herniated Disc
Herpes
High Cholesterol
Kidney Disease
Measles
Migraines
Miscarriage
Mononucleosis
Multiple Sclerosis
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Issues
Psychiatric Care
Rheumatoid Arthritis
Stroke
Thyroid Gland Malfunction
Rheumatic Fever
Tonsillitis
Tuberculosis
Ulcers
Other
Describe any Concerns & Objectives in Seeking Biofeedback Wellness Services:
BIORESONANCE CONSENT WAIVER
Bioresonance programs do not treat, diagnose or cure but create an awareness and provide relaxation training to reduce stressors within the body. If you have any questions about this form or Bioresonance please contact Jeni Shaw at 604-921-1373.
I understand Jeni Shaw or the attending Bioresonance specialists are not medical doctors nor do they portray themselves to be, but are providing Biresonance services only.
I fully understand that the Bioresonance programs are utilized for stress reduction, relaxation and training only.
I understand that Jeni Shaw or the attending Bioresonance specialists do not offer allopathic drugs, surgery, chemical stimulants or any other conventional medical treatments.
In using the Bioresonance programs, Jeni Shaw or attending specialists do not diagnose, treat, cure or otherwise prescribe for my disease, condition or illness.
I have solicited Jeni Shaw’s or attending Bioresonance 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 Bioresonance specialists to run Bioresonance 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 Bresonance and or any other programs within the scope of Jeni Shaw or the attending Bioresonance specialists for stress reduction, relaxation and awareness training.
Name
I consent to allowing Jeni Shaw access to the information submitted in this form.
Yes
No
Date (dd/mm/yy)
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