Healthy EMF Project Intake Form

Healthy EMF Project Intake Form

- An Investigation of the General Health Benefits of Spending Time in an Energy Enhancement System (EESystem) Field
My name is Dr Adrian Hekel and I am a holistic GP-Counsellor working in private practice in Brisbane, Australia.

I have become interested in the link between electromagnetic fields (EMF's) and health, and therefore wish to undertake a study to investigate the potential benefits of the EESystem field on our physical and emotional wellbeing. I am curious to see if we can replicate some of the results of the initial clinical studies across multiple 24 unit EESystems, as well as smaller unit systems.

Although anyone can participate, I am especially interested in collecting data from those of us who experience symptoms of fatigue, chronic pain, depression or anxiety which have not fully responded to conventional treatments. If you are willing, I would be grateful if you could fill out this Intake Form before commencing a block of sessions in an EESystem, and then fill out another form to track your progress after 10 hours (or 1 overnight session), 20 hours, 50 hours, 100 hours and 200 hours in a system. If you have already commenced sessions, you are welcome to fill out this Intake Form in retrospect - that is, looking back on your symptoms before you commenced your first sessions.

Note if you have spent a much shorter time in an EESystem e.g. 4 hours and noted a significant change in symptoms, it is ok to fill out the follow-up form early. You are not necessarly expected to spend 20 or more hours in the system; however if you do choose to then I would be grateful if you could fill out the follow-up form at the specified time intervals. There will also be a 12 month follow-up assessment, to see if any benefits are sustained.

I am hoping the data collected from this informal trial will become a bridge towards building awareness of this form of therapy in both mainstream and alternative medical circles.

It is important to mention, however, that we are not making or planning to make any medical claims about the use of the EESystem for specific medical conditions, but are merely investigating its ability to assist with symptom relief - as a complementary therapy - alongside standard medical care.
Date*

MonthDayYear
Date
Name

First NameLast Name
Date of Birth*

MonthDayYear
Date
Gender*
Email Address (example@example.com)
Phone Number (including area code)
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location(s) of EESystem(s) that you are visiting or intending to visit*
Number of units of each EESystem you are visiting*
Date (or intended date) of your first session in an EESystem*
Are you completing this Intake Form in retrospect (looking back upon your state of health before commencing EES sessions)?*
Fatigue Assessment

Please calculate your fatigue scores by completing the fatigue severity scale: https://www.sralab.org/sites/default/files/2017-06/sleep-Fatigue-Severity-Scale.pdf (please copy and paste this link into your browser to access the questionnaire)
Sum of responses questions 1 to 9 *
Visual Analogue Fatigue Scale Score*
Chronic Pain Assessment

Please complete the following form https://www.carepatron.com/files/brief-pain-inventory.pdf, and add up your scores below. Then save your completed form so you can forward it directly to dradrianhekel@gmail.com
Sum of responses questions 3 to 6 of Brief Pain Inventory*
Sum of all responses for question 9 of Brief Pain Inventory*
Depression, Anxiety & Stress Scores

Please calculate your depression, anxiety and stress scores by filling out the questions on the following link: https://www.thecalculator.co/health/DASS-21-Depression-Anxiety-Stress-Scale-Test-938.html
Depression Score *
Anxiety Score*
Stress Score*
Overall Disability Assessment

Please complete the following disability assessment and write down your responses below: https://www.jolietcenter.com/storage/app/media/sheehan-disability-scale.pdf
Work/School Disruption Score*
Social Life Disruption Score*
Family / Home Life Disruption Score*
Days lost in past week*
Days underproductive in past week*
General Questions

- to investigate factors which may influence outcomes & specific health benefits
Please share any other specific health problems you are currently experiencing, as well as your current treatment regime for each condition - including medication doses, if applicable*
Please share any results of medical investigations undertaken in the last 6 months which you are aware of, including blood test and imaging results which are relevant to the conditions you have listed above. If possible, could you also share your most recent cholesterol, blood sugar and iron (ferritin) results. You may send results through as an attachment to dradrianhekel@gmail.com if this is easier*
Please share what your daily diet generally consists of*
Do you have a daily exercise routine? If so, what does this involve?*
Do you have a daily meditation or spiritual practice routine? If so, what does this involve?*
In addition to the EES Sessions, are you currently engaging in other therapies such as sound healing, acupuncture or other 'energy healing' modalities? If so, could you please give some details*
Is there anything else about your medical or personal history - for example allergies, substance use or details of your current situation - that it may be useful to know about*
As part of the standard EESystem treatment protocol, it is recommended to have salt detox baths at least once after each treatment, preferably for a number of consecutive days (2 cups sea salt + 2 cups is recommended, for at least 30 minutes). Is this something you are able and willing to adhere to? *
For the purpose of this study, it is important that you keep on going with any professional medical care or monitoring that you are already receiving. Is this something you are able and willing to adhere to? *
Declaration & Consent
I hereby consent to this information being collected for the purpose of the 'Healthy EMF Project', and am aware that the information I provide here is protected, secure and confidential, and that all data collected will be de-identified. Furthermore, I am aware that any material which explain the potential health benefits of EESystem are for information purposes only, and is not intended as a substitute for professional medical advice, diagnosis or treatment. I am aware that I should never disregard professional medical advice or delay in seeking it because of something I have read here. Signature: *

Clear
Thank you!

- Dr Adrian Hekel www.adrianhekel.com
Should be Empty:

Healthy EMF Project Intake Form

Fatigue Assessment

Chronic Pain Assessment

Depression, Anxiety & Stress Scores

Overall Disability Assessment

General Questions

Declaration & Consent

Thank you!