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Quantum Biofeedback Questionnaire

Please fill in the information requested below.  All information will be kept confidential and maybe used for collection of data for research purposes.

  

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Questionnaire

Consent Form

Electrical Physical
Feedback Xrroid

What is EPFX?
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Clients Say
Programs

"Rewire" for relaxation, pattern changes, stress, and pain management, renewal, etc.

 

I understand that Sherrie Line-Coil is not a licensed medical doctor and does not portray themselves to be one. I understand the Sherrie Line-Coil cannot diagnose, treat, cure or prevent any nutritional, medical or psychological disease, disorder or condition. I further understand she cannot advise, recommend, suggest or counsel me on any medical, dietary or psychological treatment, condition, disorder or disease or perform any act that would constitute the practice of medicine for which a license is required. *Yes
No
I understand the intended purpose of biofeedback training is for relaxation and muscle re-education so I may learn to: 1. Manage my stress. 2. Manage my pain, and/or 3. Improve the quality of my life. *Yes
No
I understand biofeedback training is generally considered safe, but it is possible that biofeedback may exacerbate some emotional problems or I may become drowsy, at least temporarily, during the training sessions. Other potentially harmful side effects not yet reported may occur. I agree to advise Sherrie Line-Coil anytime I fell and side effects, so correct steps may be taken to alleviate my discomfort. *Yes
No
I understand biofeedback is not a substitute for effective standard medical treatment. Sherrie Line-Coil advised me to continue ongoing medical treatment and therapies until otherwise advised by my doctor. I understand it is important for me to stay in close communication with my doctor. He or she may want to decrease my medications during the course of the biofeedback training. I also understand there is no guarantee that biofeedback training will result in a decrease of my medication. If I do not have a family medical doctor, and wish to consult with one, I will ask Sherrie Line-Coil if hey can help me to find a family medical doctor. *Yes
No
I understand my identity and any information about me, whether I share it with Sherrie Line-Coil or they discover it on their own, will be held in the strictest confidence, except when released by me or as specifically required by law. I have the right to wave this confidentiality agreement in whole or part at any time. I also understand that I may give Sherrie Line-Coil permission in writing to contact my primary care practitioner or specialist with regard to the training provided b them and the results I obtain. I have the right to withdraw this permission at any time. *Yes
No
I have selected this service by my free informed choice. I am aware of Sherrie Line-Coil’s qualifications and certifications. I am simply seeking wellness enhancing suggestions that could reduce stress and thus improve my present health and future wellness. I am not here for medical diagnostic or treatment procedures. I am here on this and any subsequent visits solely on my own behalf. I presently seek biofeedback and other programs within the scope of Sherrie Line-Coil for stress reduction, relaxation and pain management. *Yes
No
I promise to immediately inform Sherrie Line-Coil if I am a government official or if I represent or am affiliated with a news media company or corporation. My permission to receive a session is totally contingent upon such disclosure by me and my refusing or neglecting to so would constitute a fraudulent deception on my part. *Yes
No
I agree that in the event Sherrie Line-Coil and I are unable to reach an amicable solution to any issues between us, we both agree to accept the decision of an arbitrator and shall be final and binding. The arbitration shall be governed under the laws of California. *Yes
No
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This request for information does not imply, in any way, the practice of medicine or diagnosis of a client’s condition.  Waves of Well-being reserves the right to restrict service to, or decline acceptance of, the client.