Lifestyle Form

Quantum Energy Healing, Inc.

LIFESTYLE QUESTIONS YOU WILL BE ASKED DURING

YOUR VISIT

(You do not need to answer any questions that make you feel uncomfortable but you will get the most out of the session if you share your lifestyle)

Please provide the following information:

First Name
Last Name
Middle Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
E-mail
URL

Referred By
Date of Birth -- mm/dd/yy
Place of Birth - Include city, state, country
Time of Birth if known
Number of organs removed (tonsils, adenoids, etc?)
Any Teeth removed? Counts as 1 regardless of how many have been removed
Number of prescription drugs currently used: (include over the counter drugs)
Amount you smoke/day: (Number of cigarettes, cigars, etc.)
Number of steroid type drugs used in last year:
Number of metal amalgam fillings-(Current or present during last year):
Number of street drugs used in last month:
Number of known allergies:
No. of unresolved mental factors: (Depression, anger, anxiety, sadness, etc.)
Responsibility for your health (1-10 max)
Amount of fat in diet (20%-low,30%-med,40%-high): (Include processed foods)
Do you take vitamins daily?
Personal stress level (1-10 max.):
Number of sugar type products/day: (On average) Include soft drinks, ice cream etc.
Number of exercise sessions/week: (20 minutes or more)
Number of alcoholic drinks/day (average):
Number of cups of coffee, tea, chocolate/day: (Average caffeine intake)
Number of extreme toxic exposure/year: (Radiation, insecticides, chemicals, chemotherapy, X-rays)
Number of major injuries in past: (Major car accidents, falls, etc.)
Number of major infections: (Past and present)
Number of glasses of water per day: (Include fresh juice)
How many lbs. overweight:
Your negativity level (1-10 max.):
Rate how you feel today on scale of 1-10(best):

QUANTUM ENERGY HEALING

Last modified: 07/27/08