| NAME: |
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| ADDRESS: |
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| CITY: |
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| STATE/PROV: |
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| ZIP/POSTAL CODE: |
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| HOME PHONE NUMBER: |
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| WORK/CELL NUMBER: |
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| BIRTH DATE: |
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| TIME OF BIRTH (optional): |
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| PLACE OF BIRTH (city, prov/state): |
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| EMAIL ADDRESS: |
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BIOFEEDBACK INITIAL QUESTIONS |
| # OF ORGANS REMOVED: |
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| # OF PRESCRIPTION DRUGS: |
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| # OF CIGARETTES SMOKED PER DAY: |
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| # OF STEROID DRUGS: |
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| # OF METAL FILLINGS: |
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| # OF STREET DRUGS: |
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| # OF KNOWN ALLERGIES: |
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| # OF UNRESOLVED MENTAL FACTORS: |
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I AM RESPONSIBLE FOR MY BODY
0 - N0 10 - YES: |
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% OF BODY FAT IN DIET
(AVERAGE IS 45%): |
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| PERSONAL STRESS 0 - NONE 10 - MAX: |
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| # OF SUGAR PRODUCTS PER DAY: |
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# OF EXERCISE SESSIONS PER WEEK
(20 MIN OR MORE): |
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| # OF ALCOHOL BEVERAGES PER DAY |
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| # OF CAFFEINE PRODUCTS PER DAY: |
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| # OF EXTREME TOXIC EXPOSURES PER YEAR (CHEMO, RADIATION, ETC.): |
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| # OF MAJOR TRAUMATIC INJURIES IN LIFE (MENTAL, EMONATIONAL, PHYSICAL ETC.): |
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| # OF MAJOR INFECTIONS: |
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| # OF GLASSES OF WATER PER DAY: |
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| # OF POUNDS OVERWEIGHT: |
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| PLEASE INDICATE ANY AREAS OF CONCERN OR INTEREST FOR YOUR SESSION: |
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| PERSONAL HISTORY: |
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| HOW DID YOU FIND OUT ABOUT US?: |
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