• Star Breather Therapy Client Info Form

    All information remains strictly confidential.

  • Client's Personal Information:

  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Client's Medical History:

    Please complete the following details carefully to ensure Star Breather Therapy can offer you the best support.

  • Please complete the following information:

     
  • How would you describe the severity of your health concerns?
  • Have you ever experienced abuse, been a victim of a crime, or gone through significant trauma?
  • What are your sources of emotional support?
  • Are you currently experiencing any food cravings?
  • Are you dealing with any of the following challenges?
  • How frequently do you exercise?
  • Do you smoke? Please indicate below.
  • Do you consume alcohol? Please indicate below.
  • Are you currently using recreational drugs?
  • Are you currently working night shifts?
  • Are you sleeping well?
  • Do you find it difficult to fall asleep?
  • Are you waking up regularly at night?
  • Do you feel sleepy during the day?
  • Are you experiencing stress or anxiety? Please indicate below.
  • Are you experiencing any of the physical pain types listed below? Please tick all that apply.
  • Do you have any of the respiratory conditions listed below? Please tick all that apply.
  • Do you experience any of the cardiovascular conditions listed below? Please tick all that apply.
  • Have you been diagnosed with any of the metabolic or endocrine conditions listed below? Please tick all that apply.
  • Have you been diagnosed with any of the gynecological or women’s health conditions listed below? Please tick all that apply.
  • Are you currently using any breast or other types of implants? Please indicate below.
  • How would you describe your menstrual cycle flow? Please tick the appropriate option below:
  • Could you currently be pregnant or is there a possibility of pregnancy? Please indicate below.
  • Are you breastfeeding? Please indicate below.
  • Are you currently in menopause? Please indicate below.
  • Are you currently using hormonal replacement therapy? Please indicate below.
  • Are you diagnosed with any inflammatory or autoimmune diseases?
  • Do you have any of the following skin conditions or issues?
  • Are you diagnosed with any of the neurological or psychiatric conditions listed below?
  • Please tick all that apply from the list below:
  • Have you undergone any of the surgeries listed below?
  • How would you describe your stress, coping, or mood?
  • Are you ready to make changes in your life? Please indicate below.
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  • I, [Name and Surname], hereby declare that this document was signed[Date], and is true and correct to the best of my knowledge.

  • Important Information Regarding Your Session:

     

  • Biofeedback In-depth Scan with Feedback and Report: R1,250 (includes distance or in-person frequency therapy for pathology and/or microorganisms identified).

    Biofeedback Scan with Feedback: R650 per hour

    Preparation: In-depth scans requires 2- 4 hours fasting, 8-10 hour fasting before scan is the best. Drink at least 2 glasses of water before the scan, avoid caffeinne and/or alcoholic beverages. 

    During scan: No electronics allowed. Do not cross arms and/or legs. Relax.

    Contraindications: Not suitable for pregnant women and children under 5 years.

    Payments: Pay via EFT or cash. Payment is required before the scan.

    Cancellations: 24-48 hours: full refund minus 5% administration fee; 12-hours: 50% refund; less than 12-hours: no refund (exceptions for unforeseen circumstances).

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