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Survey
Fill The Details Below
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Name
Email Address
Gender
Male
Female
DOB
Address
ZIP / Postal Code
Home Phone
Work Phone
Mobile Phone
Referred By
Family History
Cancer
Kidney Disease
High blood pressure
Epilepsy
Glandular Fever /RRF Diabetes
Asthma TB
Heart Disease
Allergic to drugs/medications
Arthritis
Depression/anxiety
Client History - previous and current diseases and conditions
Previous viruses
Main health concorns/roason for appointment
Current employment
Previous employment
Hobbies
Travel
Surgery Scars and piercing (be specific)
Vaccinations
Do you have amalgam fillings?
Yes
No
Do you have any metal implants?
Yes
No
Dentures/root fillings?
Yes
No
Any sleep disturbance?
Yes
No
Do you have a clock radio next to your bed?
Yes
No
Do you use an electric blanket?
Yes
No
Pain? (be specific)
Known allergies or reactions to foods, environment or medications
Alcohol — How many per week
Vitamins/minerals intake:
Before undergoing Bloom or Ion Cleanse it is important for us to have the following information:
Do you have a pacemaker or any other battery operated or electrical implant?
Yes
No
. Do you have any metal implants? (not amalgams)
Yes
No
Do you have any metal at all in your body?
Yes
No
Do you wear hearing aids?
Yes
No
Are you pregnant and/or breastfeeding?
Yes
No
Have you been an organ transplant recipient?
Yes
No
Are you on heartbeat medication?
Yes
No
Have you had any organs removed?
Yes
No
Are you on medication requiring levels to be?
Yes
No
Maintained through regular blood tests (i.e. warfarin)
Yes
No
Are you taking:
Blood thinning medication?
Yes
No
Blood pressure medication?
Yes
No
Epilepsy (seizure) medication?
Yes
No
Depression medication?
Yes
No
Anti-psychotic medication?
Yes
No
List any other medication
Are you a Diabetic?
Yes
No
Are you Hypoglycaemic?
Yes
No
Do you have Haemophilia?
Yes
No
Do you have anaphylactic reactions?
Yes
No
I acknowledge that I have not been given a guarantee of success for the removal of my symptoms and issues. I understand that the success of the therapy and the time frame required is dependent on the ability of my body to respond to this therapy and compliance with the given advice. When we, at Bio Energetics are testing for issues in the body, we are not making a diagnosis as this can only be done by a Medical Practitioner. Our testing is identifying stressors on the body that relate to frequencies. These frequencies have been given names, but there a numerous stressors that relate to certain frequencies. I have read and understood all the above information and questions.
*
By Checking this box I agree to the above mentioned details
SYMPTOMS THAT MAY BE ATTRIBUTABLE TO ALLERGY
Name
Circle the extent to which you experience the following symptoms, leaving blank any that you do not experience, with I indicating that you seldom experience it and S indicating that it is troublesome to you most of the time.
Head
Headache
1
2
3
4
5
Eyes
Redness, itching
1
2
3
4
5
5 Blurred vision
1
2
3
4
5
Sandy or gritty feeling
1
2
3
4
5
Seeing spots or lights
1
2
3
4
5
Dark rings under the eyes
1
2
3
4
5
Double vision (comes and goes)
1
2
3
4
5
Watering of eyes
1
2
3
4
5
Ears
Ringing in the ears
1
2
3
4
5
Hearing loss
1
2
3
4
5
Itching and redness of the outer ear
1
2
3
4
5
Recurrent ear infections
1
2
3
4
5
Earache
1
2
3
4
5
Nose, throat and mouth
Metallic taste in mouth
1
2
3
4
5
Mouth ulcers
1
2
3
4
5
Frequent sore throats
1
2
3
4
5
Post-nasal drip
1
2
3
4
5
Stuffy nose
1
2
3
4
5
Sinusitis
1
2
3
4
5
Burning urination
1
2
3
4
5
Genital itch
1
2
3
4
5
Bedwetting
1
2
3
4
5
Nervous system
Difficulty thinking clearly
1
2
3
4
5
Memory loss
1
2
3
4
5
Insomnia
1
2
3
4
5
Difficulty waking up
1
2
3
4
5
Cranky on waking
1
2
3
4
5
Overactive mental state
Irritability
1
2
3
4
5
Tenseness
1
2
3
4
5
Anxiety
1
2
3
4
5
Panic attacks
1
2
3
4
5
Overactivity
1
2
3
4
5
Restlessness
1
2
3
4
5
Destructiveness
1
2
3
4
5
Uncontrollable rage
1
2
3
4
5
Depressed mental state
Melancholy or low mood
1
2
3
4
5
Depression
1
2
3
4
5
Tearfulness
1
2
3
4
5
Feeling withdrawn
1
2
3
4
5
Lack of confidence
1
2
3
4
5
Confusion
1
2
3
4
5
Other symptoms
Being over- or underweight
1
2
3
4
5
Fluctuating weight
1
2
3
4
5
Sudden tiredness after eating
1
2
3
4
5
Sudden chills after eating
1
2
3
4
5
Vertigo
1
2
3
4
5
Suddenly feeling unwell
1
2
3
4
5
Feeling unwell all over
1
2
3
4
5
Feeling totally drained and exhausted
1
2
3
4
5
Swelling around eyes, hands, abdomen or ankles
1
2
3
4
5
Rash
1
2
3
4
5
Itching, dryness
1
2
3
4
5
Blotches
1
2
3
4
5
Excessive perspiradon unrelated to exercise
1
2
3
4
5
Chilblains
1
2
3
4
5
Cardiovascular
Rapid or irregular pulse
1
2
3
4
5
Chest pain
1
2
3
4
5
Palpitations, especially after eating
1
2
3
4
5
Tight chest
1
2
3
4
5
Pain on exercise (angina)
1
2
3
4
5
Elevated blood pressure
1
2
3
4
5
Lungs
Tightness In chest
1
2
3
4
5
Wheezing
1
2
3
4
5
Hyperventilation
1
2
3
4
5
Coughing
1
2
3
4
5
Poor respiratory function
1
2
3
4
5
Muscoloskoletal
Muscoloskoletal
1
2
4
5
Aching muscles
1
2
3
4
5
Muscular spasm
1
2
3
4
5
Shaking (especially on waking)
1
2
3
4
5
Cramps
1
2
3
4
5
Abromyatgia
1
2
3
4
5
Restless legs
1
2
3
4
5
Gastrointestinal
1
2
3
4
5
Nausea
1
2
3
4
5
Diarrhoea
1
2
3
4
5
Constipation
1
2
3
4
5
Variability of bowel function
1
2
3
4
5
Abdominal bloating
1
2
3
4
5
Flatulence
1
2
3
4
5
Burping
1
2
3
4
5
Gastric reflux
1
2
3
4
5
Abdominal distress
1
2
3
4
5
Are there any particular foods or drinks that you would say you are sensitive to ?
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