Pre-treatment Name* First Last Address Street Address Address Line 2 City Postcode AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email PhoneDate of birth* MM slash DD slash YYYY Section 1Do you have a heart pacemaker?* Yes No Not applicable Do you have a hearing aid?* Yes No Not applicable Any metal implants?* Yes No Not applicable For women - are you pregnant?* Yes No Not applicable Have you had a transplant?* Yes No Not applicable What is your reason for seeking bioresonance?*When did this first begin?What was the initial cause?What makes it worse?What makes it better?This problem affects your?* physical well-being emotional well-being mental well-being walking standing sitting lying down sleep work life exercise social life personal relationships sexual life How are your energy levels? Great Okay Fluctuating Poor What's energy? Do you have a high point during the day? Yes No Do you have a low point during the day?* Yes No Do you sleep well?* Yes No Do you drink tea or coffee?* Yes No Do you drink alcohol?* Yes No Do you smoke?* Yes No Signs / SymptomsGeneral problems, tick all that apply: Fatigue lack of energy sudden energy drops shortness of breath poor sleep insomnia nightmares night sweats snoring travel sickness unusual perspiration no perspiration at all sweat easily hair loss unintended weight loss unintended weight gain overweight underweight fluid retention heavy drinking smoking sugar cravings sugar causing neg symptoms poor appetite always hungry always thirsty peculiar tastes excessive phlegm tumours cancer none of the above Immune system, tick if you have ever had any of the following rheumatic diseases arthritis fibromyalgia chronic fatigue frequent colds ulcerative colitis morbus crohn coeliac disease hay fever chronic low grade fever swollen glands/lymph nodes measles mumps chicken pox shingles scarlet fever multiple sclerosis chronic fatigue syndrome syphilis gonorrhoea herpes HIV/AIDS none of the above Digestive system, tick if you have had any of these constipation diarrhoea dark stools very smelly stools blood in stools mucous on/in stools irritable bowel syndrome intestinal cramping loss of appetite bloating gas belching tiredness after eating no appetite in the morning hiccups, abdominal cramping / pain food allergies or intolerances abdominal distension heartburn acid regurgitation vomiting stomach or duodenal ulcers gastritis lack of stomach acid pancreatitis gallstones hepatitis liver cirrhosis gallbladder disease laxative use haemorrhoids none of the above Head, tick all that you suffer from or have suffered from* headaches migraines dizziness / vertigo concussion loss of hair premature greying of hair none of the above Mental / emotional / nervous system, tick all that you suffer from or have suffered from* moodiness irritability excessive worrying poor memory dyslexia anxiety fearfulness phobias nervousness poor concentration stuttering confusion depression short temper outbreaks of rage seizures epilepsy bipolar disorder OCD ADD ADHD drug addiction alcoholism abuse survivor none of the above Mouth, tick which apply* dry mouth / throat metallic / bitter / sour / foul taste in mouth halitosis (bad breath) bad teeth bleeding gums abscesses mouth ulcers inflammations cold sores jaw joint pain cracking jaw joint grinding teeth missing teeth root canal treatment amalgam / gold fillings crowns inlays bridges false teeth braces none of the above Ears, tick which apply* poor hearing deafness tinnitus (ringing in ear) itching of ear canal frequent ear infections ear aches none of the above Nose, tick which apply* poor sense of smell congested nose runny nose / clear discharge yellow/green phlegm recurring sinus infections polyps post nasal drip nose bleeds cold sores none of the above Eyes and Vision, tick which apply* poor vision blurred vision dry eyes itchy eyes red eyes floating spots in vision wind sensitivity light sensitivity cataracts none of the above Skin, tick which apply* eczema acne (pimples) dry skin oily skin itchy skin neurodermatitis psoriasis warts abscesses rash fungal infection athlete’s foot nail infection none of the above Respiratory system, tick which apply* cough shortness of breath asthma wheezing bronchitis pneumonia frequent colds frequent tonsillitis / sore throat / strep throat emphysema lung abscesses tuberculosis whooping cough coughing blood none of the above Urinary system, tick which apply* UTIs (urinary tract infections) kidney stones incontinence pain when urinating difficulty urinating blood in urine too frequent urgent urination wake at night to urinate urinary reflux bladder weakness none of the above Heart and circulation, tick which apply* fast pulse (resting pulse rate over 100 bpm) slow pulse (less than 60 bpm) palpitations heart arrhythmia chest pain or tightness high blood pressure low blood pressure stroke constantly feeling hot constantly feeling cold cold hands cold feet burning hands burning feet afternoon/evening fevers constant low-grade fever blushing hot flushes anaemia dizziness when standing up fainting spells bruise easily numbness or tingling sensations none of the above Hormone system* diabetes low blood sugar level enlarged thyroid hypothyroidism none of the above I am female Yes No Muscles, joints and bones injuries to joints injuries to bones injuries to muscles injuries to ligaments or sinews injuries to tailbone injuries to spine injuries to neck injuries to skull pain in joints pain in bones pain in muscles pain in ligaments or sinews pain in tailbone pain in spine pain in neck pain in skull muscle cramps limited range of motion tight neck/shoulders lower back pain lumbar prolapse / herniated disc sciatica, weak legs leg length difference RSI/OOS none of above The following things can affect one’s health, even long after they are over, list which applyPlease tick which apply in the past or now1. Any pregnancy or birth complications (ask your mother if possible)* Yes No 2. Issues that affect the whole family: Absence or illness of family members, addictions of any kind,psychological illness, (attempted) suicide, physical, sexual or emotional abuse, emotional neglect, etc.* Yes No 3. Unusual course of children’s diseases and complications from vaccinations* Yes No 4. Any serious or recurring disease?* Yes No 5. Psychological issues, traumatic or unsettling experiences* Yes No 6. Accidents (including sports accidents)* Yes No 7. Surgeries and other invasive procedures* Yes No 8. Recreational drug use (past or present)* Yes No Your close family’s medical history: Please indicate if any of your family members have or had any of the following conditions:Allergies* Yes No I don't know Heart Disease* Yes No I don't know Arthritis* Yes No I don't know Chronic fatigue diabetes* Yes No I don't know Parasites* Yes No I don't know Tuberculosis* Yes No I don't know Hepatitis* Yes No I don't know Cancer* Yes No I don't know Hypo/hyperthyroid* Yes No I don't know Epilepsy* Yes No I don't know Seizures* Yes No I don't know Additional Comments:Informed Consent Signing this form indicates that you are voluntarily and with full knowledge willing to undergo a procedure referred to as BioResonance Therapy (BRT). This is a form of modern bioenergetic science. Treatment is based on bio-physics (the physics of life processes), a field of study in German and British universities that has not yet been widely applied in medicine. The human body is seen as a sea of energy. This energy is made up of electromagnetic fields consisting of physical oscillations (waveforms). These oscillations control body processes and different cells send and receive oscillations at specific frequencies (wavelengths). Neurophysiology is one area where this is recognised and many hospitals use EEG instruments, which measure “brain waves” for diagnosis. BRT is therapy with oscillations received by the BICOM instrument either from the body or from substances, such as viruses or allergens. The BICOM instrument picks up signals from the body though electrodes and returns them in a modified form. Pathological oscillations can be ‘inverted’ through a mirror circuit to reduce or even eliminate their harmful effect. The aim of BRT is to re-establish the body’s ability to regulate itself. Allergy treatment requires abstention from some foods for a few weeks. Possible reactions are tiredness and headaches but these symptoms usually subside after a short time. As the procedure involves only the measurement of changes in the energy flow of the body with a sensitive meter, it is completely safe. The only sensation normally felt is the pressure of the electronic probe against the surface of the skin. The use of a print out recording the results makes this procedure extremely fast. At no time will the technician state or imply a client should discontinue taking any medication as prescribed by his or her physician. At no time will there be any implied or stated indication to any client to discontinue care under the direction of another physician. This procedure is not intended, implied, or stated to take the place of any conventional medical test or diagnostic procedure. At no time can this office guarantee to resolve a current health concern, however, it has been found that client compliance to the complete recommended therapy usually results in greater and more consistent changes towards better health. This office reserves the right to dismiss any client at any time due to poor compliance with the practitioner’s recommended program. I have fully read and understand the above information, the elements of my informed consent, my rights and responsibilities, and hereby give consent to the BioResonance Therapy procedure.* By using this form you agree with the storage and handling of your data by this website
