ReVitalizeLife Intake forms

Name *

First

Last

Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Email *

Phone 905-555-5555 *

Mobile 647-555-5555 *

May we send you appointment reminders to you by text? *

Yes No

Date of Birth (MM/DD/YY) *

Birth City and Country *

Age *

Gender *

Occupation *

Name *

Relation *

Phone Number *

How did you hear about Elvira?

comment *

Referred by: *

Comment *

LIST OTHER HEALTH CONCERNS AND SYMPTOMS IN ORDER OF IMPORTANCE TO YOU BELOW: *

Number of organs removed *

Personal stress 0-10 10 is maximum *

Number of Synthetic Drugs used currently *

Number of sugar products/day include soft drinks, ice cream, processedsugar, *

Amount of times you smoke/day (cigarettes/cigars) *

Number of 20 minute+ exercise sessions per week, not work related *

Number of steroid type drugs used in the last year *

Number of alcoholic drinks/day on average *

Number of metal mercury fillings present now or in the last year *

Number of cups of coffee/tea per day, or any caffeine product *

Number of street drugs used per month *

Number of extreme toxic exposures/year- radiation, insecticides, chemicals *

Number of Known Allergies *

Number of major injuries in the past including surgeries *

Number of unresolved mental factors *

Number of major infections past and present *

I am responsible for my body (from 1-10, 10 = 100% agree) *

Number of glasses of water, herbal (uncaffeinated tea) or natural fruit juice per day *

Percentage of fat in diet - including processed foods, dairy, fried, oils, animal fats *

How many pounds do you consider yourself overweight if at all *

Medication *

Dose (i.e. mg) *

Taken Since (How Long) *

Comments/Other Medications/Adverse Reactions *

How many times have you been treated with antibiotics? *

Number of root canals: *

List all over the counter medication that you take (e.g. Aspirin, Tylenol, Tums, etc.). Include dosage and frequency and any adverse reactions/allergies to medications: *

List all vitamins, minerals, botanical (herbal) medicines, Asian medicines (Chinese Patent drugs), or homeopathic remedies that you are currently taking. Indicate daily dosage: *

Mothers's Side *

Father's Side *

Siblings *

What foods do you consume on a daily basis? *

Beverages *

Do you have any dietary restrictions (religious, vegetarian/vegan, etc.)? *

YES NO

If yes, please describe *

On average, how many hours of sleep do you get per night? *

On average, how many hours do you work each day? *

What level of personal stress have you been experiencing within the last 2 weeks? *

0 1 2 (minimal) 3 4 5 (average) 6 7 8 (considerable) 9 10 (unbearable)

How would you describe the emotional climate of your home? *

other *

Is there anything that you feel is important that has not been covered? *

I, (print full name) *

understand that the Quantum Biofeedback for Stress Reduction provided by Elvira Gesummaria, is intended to enhance relaxation, increase communication within areas of the body and to educate me to possible energetic or emotional blocks that may create pain and disease. • Quantum Biofeedback is non-invasive, safe, and objective and utilizes the body’s own innate intelligence to re-establish communication within itself. • I understand that Quantum Biofeedback sessions are not a substitute for medical diagnosis, treatment or medications. • I am aware that the practitioner does not diagnose illness or disease, nor does the practitioner prescribe medications. • I understand that participation in a session is voluntary and that at all times I may choose to end my participation. • In addition, certain sessions entail light tapping and touching of energy points on the body. The practitioner will inform me where tapping and/or touching by the practitioner and/or myself will occur, thus allowing for my ongoing consent. • I understand that information exchanged during any session is educational in nature and is used at my own discretion, and Elvira will not be held under any legal responsibility or obligation for decisions made by you, the client, as a result of receiving an intuitive reading or healing.. • I also understand that any information imparted during sessions is confidential and will not be released without my prior consent, except as required by law. • I understand that by providing this informed consent I am assuming full responsibility for my Biofeedback session and I hold harmless the practitioner Elvira Gesummaria. Payments and Rates: • I understand that payment is due before my appointment by e-transfer, credit card, or paypal. • I understand that packages must be paid in full before first appointment. • I am aware of session costs (in CAD): $150/hour (pay as you go) Package of 4: $500 ; Package of 8: $900 Animal Session: $150/hour (pay as you go) I understand that packages are to be used within 6 months of purchase date. • Since time has been especially reserved for me, I understand that a 24 hour cancellation notice is expected and missed appointments will be charged. • If I have any questions or concerns, I will address these promptly with the practitioner. I hereby authorize, Elvira Gesummaria to provide me with Quantum Biofeedback for Relaxation and by signing below I agree to all the terms above. **Client Signature (Full Name) *

BIOFEEDBACK HEALTH INTAKE FORM

Biofeedback Intake form

Emergency Contact:

How did you hear about Elvira?

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

Biofeedback Device questions
these values will be entered before the initial testing

List all names of prescribed medication currently being taken. Include dosage, frequency, how long you have been taking it.

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

iNFORMED cONSENT

Services

Company

Support

BIOFEEDBACK HEALTH INTAKE FORM

Biofeedback Intake form​

Emergency Contact:

How did you hear about Elvira?

CHIEF HEALTH CONCERNS​Please describe your primary health concern below:

Biofeedback Device questionsthese values will be entered before the initial testing

List all names of prescribed medication currently being taken. Include dosage, frequency, how long you have been taking it.

PREVIOUS HEALTH HISTORY/FAMILY HISTORY

LIFESTYLE

ENVIRONMENT

iNFORMED cONSENT

Services

Company

Support

Subscribe

Biofeedback Intake form

CHIEF HEALTH CONCERNS

Please describe your primary health concern below:

Biofeedback Device questions
these values will be entered before the initial testing