Client Intake Form | Quantum Waves Hypnotherapy & Biofeedback

Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Time of Birth
Place of Birth*
Home Phone*
Cell Phone
Email*
Number of organs removed
(e.g. tonsils, appendix, etc. - count ovaries individually)
Number of prescription or over the counter medications taken daily
Number of times a day you smoke or chew tobacco
Number of steroid type drugs taken in the past year, include inhalers
Number of silver amalgam type dental fillings in current teeth
Number of street drugs used each month
Number of known allergies
Number of persistent thoughts by category e.g.; work, relationship, health issues, etc.
On a scale of 1-100% how much do you feel it is your responsibility for your health*
Amount of fat in your diet by % (average American diet is at 40%)
Rate overall stress level (1–10 with 10 highest)
Please enter a number from 1 to 10.
Number. of times a week you exercise 20 minutes or more
Number of alcoholic drinks consumed daily, or average out for week
Number of caffeine products consumed daily e.g.; coffee, tea, Red Bull, etc.
Number of toxic exposures e.g.; CT scan, chemotherapy, radiation therapy, etc.
Number of past injuries emotional & physical – include surgeries
Number of past major infections that required hospitalization or long term medication
Number of glasses of pure water you drink on average per day
Do you feel you are overweight? If so, by how much?
Do you wear a pacemaker?*
- Yes
- No
Are you pregnant?
- Yes
- No
Have you ever had electro-shock therapy?
- Yes
- No
Signature of client - (parent for minor)*
Entering you name below functions as a "digital signature".
Phone
This field is for validation purposes and should be left unchanged.