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Information for Client's Appointment
To help save time on your first visit, please fill in ALL the following fields. All information is kept confidential and is bound by the practitioner to client relationship. Thank-you.

*indicates required fields 
  *Name:
  *Address:
  *City:
  *State/Province:
  *Zip/Postal Code:
  *Home Phone:
  *Cell/Work Phone:
  *Birth date:
  *Time of Birth:
  *Birthplace: City & Country:
  *Email Address:
  EPFX/SCIO Initial Questions:  please enter 0-10 in the following questions
  *no. of Organs Removed: (all teeth removed = 1):
  *no. of Prescription Drugs on currently:
  *no. of cigarettes smoked /day:
  *no. of Steroid drugs / year:
  *no. of Metal Fillings:
  *no. of Street drugs / month:
  *no. of known allergies:
  *no. of unresloved mental factors (greed, etc.):
  *I am responsible for my body (1 is low):
  *Amount of fat in diet (1=10%):
  *ersonal Stress (1 is low):
  *no. of Suger products / day:
  *no. of 30 min Exercise sessions / week:
  *no. of Alcoholic Beverages / day:
  *no. of Caffeine products / day:
  *no. of Extreme Toxic exposures / year (chemo, etc):
  *no. of Major Injuries in past:
  *no. of Major Infections in past:
  *no. of Glasses of water / day:
  *no. of Pounds you feel overweight:
  *What areas are of interest for your session?:
  *Relevant Personal History::
  *Referred By::

Please note: We are not medical doctors, and, as such, by law, we cannot diagnose, treat, cure or prevent any psychological disorder or disease. If you are experiencing any severe symptons consult a licensed Physician immediately.
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