Returning Client Intake Form (confidential)
Name
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First Name
Last Name
Shipping Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of birth (MM/DD/YYYY)
*
Place of birth
*
Gender
*
Please Select
Male
Female
Occupation
*
Medications (list them out):
*
Supplements (list them out):
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Emergency Contact (please include name and phone number):
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Please check if you have or have had any of the following:
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AIDS
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
Goiter
Gout
Heart Disease
Hepatitis
Hernia
Herniated Disc
Herpes
High Cholesterol
Kidney Disease
Liver Disease
Measles
Migraine Headaches
Miscarriage
Mononucleosis
Multiple Sclerosis
Osteoporosis
Pacemaker
Parkinson's Disease
Pinched Nerve
Pneumonia
Polio
Prostate Problems
Psychiatric Care
Rheumatoid Arthritis
Rheumatoid Fever
Scarlet Fever
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis
Tumor Growths
Ulcers
Other
Family History: Please indicate if any family members have had any of the following medical problems:
Diabetes
Hypertension
Stroke
Alcohol Problems
Mental/Emotional Problems
Heart Disease
Hepatitis/Liver Disease
Cancer
Congenital Problems
Other
Number of organs removed:
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Number of steroid type drugs used in the past year:
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Number of silver fillings in your mouth
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Number of all known allergies:
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Number of major infections in the past
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Personal Stress (on a scale of 1-10):
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Please Select
0
1
2
3
4
5
6
7
8
9
10
Average amount of times you exercise in a week:
*
Please Select
0
1
2
3
4
5
6
7
8
9
More
Average amount of water you drink in a day (in cups):
*
Please Select
0-5
6-10
11-15
16-20
Describe any changes since your last appointment and please write down any questions you have or topics you would like to cover with Karen during your appointment:
*
Please take a clear selfie with NO additional people or animals in the photo. It is preferred that your eyes are fully visible (no sunglasses, hats, or obstructions) to provide a more accurate scan.
OR upload photo with the same specifications listed above.
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Terms of Care: I understand that the attending practitioners are not allopathic doctors (MDs) and do not portray themselves to be but are providing biofeedback and wellness services. I understand that the services provided identify energetic imbalances. Procedures utilized include stress reduction protocols, nutritional wellness consultation and biofeedback. I fully understand that the attending practitioners do not offer allopathic drugs, surgery, chemical stimulants, or any other conventional treatments. In addition, we do not diagnose, treat or otherwise prescribe for my disease, conditions or illness, perform any act that would constitute the practice of medicine for which a license is required. I have solicited the attending practitioners’ 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 heath. I am fully aware and release the practitioner to do biofeedback testing, wellness consultation and other stress reduction protocols. By signing below, I acknowledge that I have read and understand all parts of this waiver, that I had the opportunity to ask any questions with regard to the described procedures, and that I hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on this and any subsequent visit solely on my own behalf.
*
Terms of Care: I understand that the attending practitioners are not allopathic doctors (MDs) and do not portray themselves to be but are providing biofeedback and wellness services. I understand that the services provided identify energetic imbalances. Procedures utilized include stress reduction protocols, nutritional wellness consultation and biofeedback. I fully understand that the attending practitioners do not offer allopathic drugs, surgery, chemical stimulants, or any other conventional treatments. In addition, we do not diagnose, treat or otherwise prescribe for my disease, conditions or illness, perform any act that would constitute the practice of medicine for which a license is required. I have solicited the attending practitioners’ 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 heath. I am fully aware and release the practitioner to do biofeedback testing, wellness consultation and other stress reduction protocols. By signing below, I acknowledge that I have read and understand all parts of this waiver, that I had the opportunity to ask any questions with regard to the described procedures, and that I hereby affirm: I am not here for medical diagnostic or treatment procedures and I am here on this and any subsequent visit solely on my own behalf.
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I have read and understand the Terms of Care.
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