First name:
Last name:
Date of birth:
Place of birth:
Approximate time of birth:
(0) What is your expectation for this treatment?
(1) Have you ever had any organs removed? Example tonsillitis, uterus, appendix? If so, list which ones here:
(2) Have you had any Root Canals? if so How Many?
(3) Have you had any wisdom teeth removed, if so how many?
(4) Do you have any amalgam fillings in your teeth and, if so, how many?
(5) Do you vape or smoke cigarettes and, if so, how many a day?
(6) Have you been taking any steroids in the last year and, if so, for what condition?
(7) Are you taking any synthetic pharmaceutical drugs at the moment? if so, how many and for what condition/s?
(8) Are you taking any recreational or “street drugs” at the moment?
(9) Have you ever had any anaphylactic allergies or any allergies that should be noted?
(10) Do you have any mental emotional problems at the moment? Eg: depression, anxiety, phobias, etc
(11) Do you eat meat? If so, how often, ie daily, weekly, rarely etc, If you are you a vegetarian, please indicate here:
(12) Currently, what is your level of personal stress on a scale of 0 to 10, with 10 being the highest?
(13) Do you have sugar cravings, and do you consume sugar, chocolates etc on a daily basis?
(14) How many exercise sessions a week, not including work, do you do, and if any, what types and for how long?
(15) Do you drink alcohol and, if so, how much and how often?
(16) Do you drink caffeine and, if so, how much and how often?
(17) Have you had any x-rays or exposure to chemical toxins or radiation, or been on long-distance flights in the last year?
(18) Have you ever broken any bones, ever had a car accident or experienced any trauma to your body?
(19) Have you ever had any serious viruses or food poisoning or infections, problems with bacteria in your body?
(20) How much water do you drink per day, and is it Rainwater, Filtered water or town tap water?
(21) Are you currently overweight and, if so, by how many kilos?
(22) Do you have issues with constipation? And how often do you move your bowels, ie daily, every 2 or 3 days etc?
(23) How often do you do yoga or meditation?
(24) Do you have other issues that are causing you stress that you can share?
(25). Have you or anyone close to you had the COVID-19 vaccination?
5 + 2 = ?
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