Biofeedback Intake Form

Thank you for taking the time to fill out this form before your session.

Suppression or obstruction to cure (SOC) questions

These questions identify lifestyle issues, medical history and helps the biofeedback device identify any particular risks for yourself.
The SOC is an overall value calculated by the device to reflect your personal impediment to healing. Bringing awareness to your
health is the first step to healing.

Date *

Referred by?

First name *

Last name *

Date of Birth *

City and Country of Birth *

Please answer the questions below with a number/amount based on each question. If the answer is zero, just leave it blank.

1. How many organs have you had removed (this includes teeth):

2. Number of synthetic drugs you are currently using:_

3. Amount of times you smoke per day (cigars, cigarettes):

4. Number of steroid type drugs used in the last year:

5. Number of metal amalgams (mercury) fillings:

6. Number of street drugs used per month:

7. Number of all known allergies:

8.Number of unresolved mental factors:

9. Rate this statement (0 do not agree – 10 completely agree) “I am responsible for my body”:

Please answer the following with a rating of 0 - 10, 10 being the maximum.

10. Rate your personal stress level from 0 – 10 (10 is extreme)

If your personal stress is 7 or higher please complete these additional questions below (rate from 0-10) If your stress is 6 or lower, please move to question #11.

10a. Interpersonal stress:

10b. Job or school stress:

10c. Struggle; self or money:

10d. Stress from sickness:

10e. Family stress:

10f. Stress from desire for things to be different:

10g. Problem with sweat:

10h. Problem with bowels:

10i. Problem with urine:

10j. Problem with mucous:

10k. Problem with menses:

10l. Problem with breath:

10m. Problem with skin:

10n. Problem with sleep:

11. Number of sugar products per day (refined sugar, include bread):

12. Number of exercise sessions per week (20 mins or more, inducing a sweat):

13. Number of alcoholic drinks per day (on average):

14. Number of cups of coffee/tea per day (any caffeine product):

15. Number of extreme toxic exposures per year (radiation, chemicals, insecticide):

16. Number of major injuries in the past:

17. Number of major infections (past and present):

18. Number of glasses of water per day:_