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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?
How it works
What does it test?
Can it help me?
Features
Clients Say
Programs

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

Name *
E-mail Address: *
Address
City/State/Zip
Phone
Do you have, or have you ever had Arthritis	Yes No
When and what kind
Do you have, or have you ever had Back Problems	Yes No
When and describe location
Cancer	Yes No
When and what kind?
Diabetes	Yes No
When
Dislocations/Fractures	Yes No
When and where and what kind
Edema	Yes No
When
Gout	Yes No
When
Headaches	Yes No
When
Heart Problems	Yes No
When and what kind
High Blood Pressure	Yes No
When and is High Blood Pressure controlled by medicine
Kidney Disease	Yes No
When
Hypoglycemia (low blood sugar)	Yes No
When
Low Blood Pressure	Yes No
When
Neurological Diseases	M.S. Parkinsons Other
When and descrbe other
Muscle Cramping	Yes No
When
Neck Problems	Yes No
When and what kind
Osteoporosis	Yes No
When
Skin Problems	Rashes Eczema Sporiasis Other
When and descrbe other
Stomach Problems	Yes No
When and what kind
Surgery	Yes No
Where and what kind
TMJD	Yes No
When
Varicose Veins	Yes No
When
Recent Injuries or accidents	Motor Vehicle X-rays taken
When and where
Contagious Diseases?	Herpes AIDS Other
When and descrbe other
Are you pregnant?	Yes No
How many months?
Do you have a Pacemaker?	Yes No
How long
Other health problems or things you would like us to know about you?
I understand that I am I am requesting service on my own initiative and that I realized that Sherrie Line-Coil does not diagnose aliments or prescribe treatments. I release Waves of Well-being/Sherrie Line-Coil from any liability for claims resulting from the use of its services. *
Place of Birth (include: City, State, Country)
Date of Birth


* Required

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.