Biofeedback & Quantum Energy Healing Demographics Form for New Clients

Biofeedback & Quantum Energy Healing Demographics Form for New Clients

Regardless of the nature of your appointment, I use a quick (or comprehensive) Biofeedback Scan to gain information about your body's needs and priorities.
Biofeedback and Quantum Energy Healing are included at no additional charge with any 2-hour ENHANCED treatment/appointment. The information I gather with biofeedback allows me to individualize your treatment, as well as make recommendations to help you improve your health and wellbeing. Quantum Energy Healing will enhance your healing experience.

Your Biofeedback Scan will reveal to me, among other things, which of your muscles are acutely or chronically stressed. This means that I no longer need to spend 30+ minutes of your treatment time searching for the source of your problem with my hands. (Remember that the source of your problem is rarely ever in the same place where you experience the symptom!) For you, this translates to a more efficient, effective, and longer-lasting treatment.

For more information about Biofeedback and Quantum Energy Healing, visit: https://www.transformationswellness.net/bfqe/

For information about how Biofeedback and Quantum Energy Healing can help you lose weight and restore or maintain your health, visit: https://www.transformationswellness.net/weightloss/

The following questions are required if you choose to include Biofeedback and Quantum Energy Healing - as a stand-alone service, or as an add-on to your scheduled treatment.

Answering these questions in advance will prevent the need to use your valuable treatment time to answer them at the time of your appointment.

DETAILS ARE IMPORTANT, as they are with numerology, astrology, and biorhythm tracking. Please answer all questions fully and completely, to the best of your knowledge.
Please enter your current FULL LEGAL name (full first, full middle, and full last):
Email
example@example.com
Phone Number
Please enter a valid phone number.
Appointment Date (if you have not yet scheduled your appointment, do so here: https://www.transformationswellness.net/schedule/):

Month Day Year
Date
Do you have a pacemaker, seizure disorder, or are you currently pregnant? (checking "yes" disqualifies you from receiving biofeedback or quantum energy healing, but you can still receive services like massage)

yes no
The answers to the following questions are important for customizing your biofeedback scan, in order to get accurate results. Please answer each question as accurately as you can.
Biological gender:

Male Female Both male and female sex organs
Please rate your negativity (0-10):
Do you have one or more known inherited disorders?

yes no
Are you a professional athlete?

yes no
Please rate your current happiness (0-10)
How many of your organs have been removed? (ie - appendix, tonsils, ovaries, uterus, etc)
Number of synthetic drugs used currently, including over-the-counter types ("synthetic" does not include natural plant medicines or supplements. You don't need to list them, just type a number.):
Average number of cigarettes, cigars, or joints smoked daily:
Number of steroid-type drugs used in the last year:
Number of metal amalgam fillings present in your mouth during last year:
Number of street drugs used per month:
Number of all known allergies:
Number of unresolved mental factors (anger, greed, desire, sadness, fear, etc)
Rate your agreement to this statement: "I am responsible for my body" (0-10)
Average daily servings of whole plant foods in diet (unprocessed fruit, vegetables, whole grains, etc):
Percentage of fat in diet, including processed foods:
Rate your personal stress (0-10):
Average number of sugar products consumed daily (includes white flour/bread products, soft drinks, ice cream, pastries, etc):
Average number of exercise sessions weekly (20-minutes or more, do not include work):
Average number of alcoholic beverages daily:
Average number of caffeinated products per day (coffee, tea, cola, chocolate, etc)
Average number of extreme toxic exposures per year (radiation, chemotherapy, insecticides, chemicals, accidental exposures, etc)
Number of major injuries in past (include surgeries and emotional trauma)
Number of major infections, past and present (Include STD's and all health- and life-threatening infections. You don't need to list them - just type a number.)
Average number of 8-ounce glasses of water or natural (not bottled) fruit juice daily:
If you consider yourself overweight, how many pounds over your ideal healthy weight are you currently? (enter "0" if not applicable, or if you are underweight. This is YOUR opinion - not your doctor's opinion.)
Date of birth:

Month Day Year
Date
Birth location (city and state):
Time of birth (if known):
Optional: If you are seeking assistance with weight loss, please fill in the following blank fields (I can help you take these measurements at your appointment, if you don't have a tape measure, accurate scale, etc):

Height in inches: ex: 67"
Weight in pounds:   ex: 150 lbs
Waist circumference:   ex: 32"
Thigh circumference:   ex: 12"
Abdominal fat thickness:   ex: 2"
Triceps fat thickness:   ex: 1"
Should be Empty: