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Knowledge, Rejuvenation
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Client Intake Form

Full Name*

Date of Birth*

Time of Birth

Time

:HoursMinutes

Phone Number

Email Address*

Address

Country/Region

Address*

City*

Zip / Postal code*

Emergency Contact

Name

Relationship

Phone

Health History*

High Blood Pressure

Heart Conditions

Digestive Issues

Chronic Fatigue

Allergies

Pain or Inflammation

Anxiety/Depression

Autoimmune Disorders

Sleep Disorders

Other

Medications or Supplements

Additional Health Questions

Number of organs removed

Number of cigarettes smoked per day

Number of steroid drugs used

Number of amalgam fillings

Number of street drugs used

Number of unresolved mental factors

Responsibility for own health (1-10)

Percentage of fat in diet

Personal stress (1-10)

Number of sugar products per day

Number of exercise sessions per day

Number of alcohol drinks per day

Number of cups of coffee or tea per day

Number of X-rays/toxic exposures in the last year

Major infections in lifetime

Major injuries in lifetime

Glasses of water per day

Number of pounds overweight

Are you pregnant?

Do you have a pacemaker or other electrical device implants?

Energy Work Experience

Have you experienced energy work before?

Yes

No

If yes, what types and how did they help?

Support & Intentions

What do you most want support with right now?

What are your healing goals or areas of focus?

Consent & Acknowledgment

By submitting this form, you acknowledge that Quantum Biofeedback is a complementary modality and not a substitute for medical care. You agree to take full responsibility for your healing process.

Signature*

Date*

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