BioMagnetics New Client Form

BioMagnetics New Client Form
Please type your answers into the form below (do not print and mail to us). Be sure to fill in all pages thoroughly and sign on Page 3, then hit the "Submit Form" button at the end to send your completed form to us. All information is strictly confidential and is transmitted via SSL encryption.
Client's Full Name*

First NameLast Name
If this is for a child, please put a parent's name here:

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Cell Phone Number*
Alternate Phone Number
We may email you appointment reminders. We also occasionally send notices, important updates, and other health-related information by email, although you can choose not to receive these emails at any time by notifying us of your preferences. We will never share your email address with anyone.*
Please enter your email address here.
Gender*
Date of Birth*

MonthDayYear
Height*
Weight*
Occupation*
How did you find out about us and also how did you first find out about biomagnetics? If a person referred you, please put down their name.*
What are your main health concerns or conditions?*
What are you hoping the magnets will help you with?*
Have you had any major surgeries or major injuries?*

YesNo
Please describe the surgeries or injuries here:*
Do you have any implanted electronic devices such as a pacemaker or surgically implanted metal pieces?*

YesNo
Please give details on the devices or metal here:*
Do you have any areas of chronic or recurring pain?*

YesNo
Please tell us where the pain is and any other details:*
Are you doing any other types of treatment such as chiropractic, acupuncture, supplements/vitamins/herbs, IV drips, physical therapy, etc.? Please tell us about them here:

	How Many?
Scars from surgeries/injuries?
Body Piercings (other than earrings)?
Silver/Amalgam Dental Fillings?
Root Canals?
History of Heart Attacks?

	Select
Drug Addiction?
Alcoholism?
Smoking?
Cancer?

	Select
Hysterectomy
Abnormal Pap Smear
Menopause
Past Miscarriage
Currently Pregnant
Lactating Mother
Currently Trying to Get Pregnant

Thank you for providing us your information. We have only one step left. Please read the following disclosure and sign your name using your mouse at the bottom. Then Submit, and we are done!
Consent and Disclosure Form

Please read the following and provide your name and signature below as appropriate:

1. Moses Nutrition is not a medical facility, and it's operators Nikki Moses and Kristina Law are not licensed physicians.

2. The services being provided by them and Moses Nutrition, Inc. is alternative or complementary to healing arts services licensed by the state of California.

3. The services to be provided are not licensed by the state.

4. The services provided may involve:

     A. BioMagnetics (the use of magnets on the body)

     B. Nutritional consultation

     C. Various forms of muscle testing and other non-medical forms of testing and stress-reduction techniques.

     D. Dietary supplements may be recommended as well as diet suggestions, detoxification procedures and lifestyle recommendations.

5. All biomagnetic therapy, other nutrition techniques and supplements are recommended/provided soley for the purpose of reducing stress and balancing the body's energy and chemistry. None of the services or products recommended or provided by Moses Nutrition, Inc. or Nikki Moses or Kristina Law is intended as diagnosis, prevention, treatment or prescription for any condition or disease and is not a substitute for proper medical care by a licensed doctor.

6. Nikki Moses and Kristina Law have diplomas in Nutritional Balancing Science as provided by Westbrook University of Wierton, West Virginia, and taught by Dr. Lawrence Wilson of Prescott, Arizona. Nikki Moses and Kristina Law are also trained in various other techniques such as Nutrition Response Testing and Morphogenic Field Technique and BioMagnetics as provided by those various independent training entities. Nikki Moses and Kristina Law work as nutritional consultants only.

By signing below, I acknowledge that I have read and understood the information above, that I am willingly choosing to receive magnet therapy, and that I request that Moses Nutrition, Inc. and its staff perform one or more of the above services for the purpose of supporting my health or that of a minor under my care.
Type your name here:*
Date:*

MonthDayYear
Client Signature (use your mouse or touch screen to sign):*

Clear
Thank you! Be sure to click "Submit Form" below. Have a happy and healthy day!
Should be Empty:

	Mild	Moderate	Severe
Joint Pain
Joint Stiffness
Back/Neck Pain
Arthritis, Osteo
Arthritis, Rheumatoid
Muscle Pain
Muscle Weakness
Muscle Cramps
Fractures
Osteoporosis
Gout
Nerve Pain

	Mild	Moderate	Severe
Cough
Asthma
Post-nasal drip
Sinus Congestion
Ear Infection
Ringing in Ears/Tinnitus
Allergies
Emphysema
Chemical Sensitivity
Infections/Viruses
Non-Cancerous Tumors
Multiple Sclerosis
Parkinson's Disease

	Mild	Moderate	Severe
Rapid Heart Beat
Heart Palpitations
Poor Circulation
Vertigo/Dizziness
Dizzy upon standing
Low Blood Pressure
High Blood Pressure
Angina
Arteriosclerosis
High Cholesterol
High Triglycerides

	Mild	Moderate	Severe
Irritable before meals
Can't Skip Meals
Hypoglycemia
Food Allergies
Loss of Appetite
Diabetes, Type I
Diabetes, Type II
Pre-Diabetes

	Mild	Moderate	Severe
Rash
Eczema
Fungal Infections
Candida
Psoriasis
Hives
Hair Loss
Slow Wound Healing
Gum Disease
Tooth Decay
Blurred Vision
Cataracts
Glaucoma
Macular Degeneration

BioMagnetics New Client Form

Please type your answers into the form below (do not print and mail to us). Be sure to fill in all pages thoroughly and sign on Page 3, then hit the "Submit Form" button at the end to send your completed form to us. All information is strictly confidential and is transmitted via SSL encryption.

Tell us about your symptoms:

Please click the appropriate box next to any of the below symptoms that you have experienced within the last few months including any long-term conditions. There is room at the end of this section for additional comments and symptoms.

Thank you so much! We look forward to getting you started! This form does not book your appointments for you, so be sure to schedule your magnet session using our online scheduling at www.MosesNutrition.com, or you may call our office to schedule.

Great! If you do not receive the email with the copy of your form, be sure to check your junk mail. If you think of new information you would like to share with us, you can send it to us by replying to that email or by emailing us via our website.

Great! If you think of new information you would like to share with us, you may email us via our website.

Thank you for providing us your information. We have only one step left. Please read the following disclosure and sign your name using your mouse at the bottom. Then Submit, and we are done!

Thank you! Be sure to click "Submit Form" below. Have a happy and healthy day!

	Mild	Moderate	Severe
Constipation
Diarrhea
Intestinal Gas/Bloating
Heartburn
Celiac Disease
Ulcer
Stomach Pain
Colitis
Gall Stones
Hemorrhoids
Liver Cirrhosis
Diverticulitis

	Mild	Moderate	Severe
Fatigue
Hypothyroidism
Low Body Temperature
Cold in Winter/Dry Skin
Tend to Gain Weight
Tend to Lose Weight
Hyperthyroidism/Graves

	Mild	Moderate	Severe
Bladder Infections
Difficult/Painful Urination
Frequent Urination
Kidney Stones
Water Retention/Edema

	Mild	Moderate	Severe
Sinus/Tension Headaches
Migraine Headaches
Anemia
Easy Bruising
Trouble sleeping
Seizures

	Mild	Moderate	Severe
Anger
Anxiety
Brain Fog
Confusion/Poor Memory
Depression
Irritability
Mind Races
Mood Swings
Panic Attacks
Attention Deficit
Hyperactivity

	Mild	Moderate	Severe
Anorexia
Autism
Bipolar or other Mental Disorder
Delayed Development

	Mild	Moderate	Severe
Premenstrual Syndrome
Cramps
Heavy Periods
Light/Irregular Periods
Ovarian Cysts
Fibroids/Fibrocystic Breasts
Yeast Infections
Hot Flashes
Infertility