Client Intake Form

The Client Intake Form, below, provides us with all the necessary information about you and your wellbeing, so that you can get optimal results from your Biofeedback Session.

This form is secure and all of your details are kept in the strictest confidence. Please take your time completing the form filling in as many of the fields as you can.

Client Intake Form

Please note that all fields followed by an asterisk must be filled in.

Male/ Female*

	Male
	Female

Full Name*

Date of Birth*

Time of Birth*

Location of Birth- City*

Location of Birth- State*

Location of Birth- Country*

Home Phone*

Business Phone

Number of Organs Removed (all teeth=1)*

No. Prescription Drugs*

No. Cigarettes /day*

No. Steroid Drugs*

No. of Metal Fillings*

No. of Street Drugs Used in Last Month*

No. of Allergies*

Unresolved Mental Factors (anger, resentment, greed)*

I am responsible for my body (0=No 10=Yes)*

% Fat in diet (Average is 45%)*

Personal Stress (0=None 10=Maximum)*

Sugar Products /day (Incl soft drinks)*

Exercise Sessions /week (20mins or more)*

Alcoholic Drinks /week (average)*

Caffeine Products /day *

Extreme Toxic Exposures /year (chemical, radiation, insecticides)*

No. Major Traumatic Injuries (mental, emotional, physical)*

Major Infections (Past and Present)*

Glasses of Water /day*

Kilos You Feel Overweight*

Please tick if you have any of the following*

	Pacemaker
	Pregnant/Suspected Pregnancy
	Epilepsy/Suffer from Seizures
	None of the Above

Please indicate areas of interest for the SCIO biofeedback session

Personal History *

Referred By

Please enter the word that you see below.

Disclaimer: The purpose of Biofeedback is for stress relief and relaxation training only. We are not medical doctors and, under law, cannot diagnose, treat or cure any condition or disease, either physical or psychological.

WELL FOR LIFE
Biofeedback Practitioners

Carrum Downs
Melbourne, Australia
Ph: +61 439 107 389