Bioresonance Intake Form

Bioresonance

Bioresonance focuses on the system that is the most stressed as determined by a full body scan. It is recommended that this system receive therapies for 4 to 6 weeks. Along with this approach, I may help you with one other issue that you consider to be the most important. Please note that applying therapy to “everything” all at once is not recommended. This is a process. The basic rule of thumb is that for every year you have been ill, you need a month of therapy. As with all my programs, this may help the body heal from the inside out.

Name

First Name

Last Name

Address

City

State

Zip

Country

Phone (including area code)

Sex:

Male

Female

Height

Weight

Birthdate - (month, day and year)

YYYY

Indicate one below:

Ideal Weight

Under Weight

Over Weight

How were you referred - if you check other please respond below:

Internet

Other

If applicable, name of person who referred you:

Date

Date you cut your nails

YYYY

Please list any organs you have had removed - including teeth:

List the medications you are currently taking:

List the supplements you are currently taking:

Type of water you are drinking:

Average amount of water consumed daily in ounces:

Average number of alcoholic drinks consumed daily:

Average number of coffee, tea or other caffeinated products consumed daily:

Average number of sugar containing products you consume daily: (including soda ice cream etc):

Personal Stress - (indicate with a number 1-10, with 10 being the max):

List your main sources of Stress:

Time you go to bed:

Average number of hours you sleep per night:

Are you sensitive to the environment, taking supplements, medications, or other sources: If yes, included details below:

Yes

If you responded yes, please share details regarding your sensitivities:

How would you rate your overall health on a scale of 1 - 10 with 1 being Very Poor and 10 being Excellent:

Please list ONE major health issue you are experiencing that you feel is the MOST important:

Please list specific issues you are experiencing and in the follow up box, list the issues that are the most important:

From the list above which issues are the most important:

Please sign the waiver in the box below:

Wellness & Bio-Feedback Research and Training Consultation Waiver 1. I fully understand that Doreen McCafferty is not an allopathic practitioner and does not portray herself as one but is a wellness consultant and Bio-Feedback technician. 2. I fully understand the difference between the practice of allopathic (conventional) medicine, nutritional wellness consulting, and bio-feedback. 3. I fully understand that the services provided by Doreen McCafferty are not allopathic, but are strictly behavioral, stress or bio-feedback in nature. 4. Any reference to patient within this frequency balancing is solely due to the technical terminology within the Oberon program and in no way implies that the client is a medical patient. 5. I fully understand that Doreen McCafferty performs her services within the parameters of a natural health care and wellness system using bio-feedback and stress reduction. 6. I fully understand that Doreen McCafferty does not offer allopathic drugs, surgery, chemical stimulants, radiation frequency balancing, or any other conventional treatments. In addition, she does not diagnose, treat, or otherwise prescribe for any disease, condition, or illness and that my wellness and stress parameters are being measured. 7. I have solicited Holistic Wellness from Within LLC and Doreen McCafferty’s services in good faith, exercising my free will and following my dictates of my own conscience which allows me to select what I understand is most beneficial to my health. 8. I also exercise my free will in asking Holistic Wellness from Within LLC and Doreen McCafferty for her opinion on items and situations which may expedite my good health; it is my choice should I accept to utilize or apply any of those ideas or suggestions at any time. 9. If I desire any services not provided by Holistic Wellness from Within LLC, which is my prerogative, I fully understand that I should seek them elsewhere. 10. I presently seek counsel, advice, opinions, bio-feedback, or points of view and/or programs within the scope of Holistic Wellness from Within LLC and Doreen McCafferty’s wellness and stress reduction practice. I am fully aware and release Holistic Wellness from Within LLC and Doreen McCafferty to do bio-feedback stress interpretations and frequency balancing. 11. I fully understand that the services provided by Holistic Wellness from Within LLC and Doreen McCafferty are not generally accepted and/or recommended by allopathic doctors (MD’s) or other conventional health care professionals. I realize that insurance payments are not accepted for bio-feedback services from Holistic Wellness from Within LLC. 12. I understand that payment is expected prior to receiving service, unless otherwise arranged prior to my scan. 13. I understand that no refunds are issued for bio-feedback services. 14. By signing below, I acknowledge that I have read and understand all parts of this waiver and that I have had the opportunity to ask any questions with regards to all such procedures. 15. The Food and Drug Administration have not evaluated these statements. This product is not intended to diagnose, treat, cure or prevent any disease. 16. I understand that it is my responsibility to present myself when observing or requesting scans and services, including bio-feedback, from Holistic Wellness from Within LLC, when employed by the FDA or any other governmental agency.

Date

YYYY