Pre-Treatment Form - Marie Reynolds London

The following form is required to gather as much detail as possible. Please take your time to read through all the questions and answer correctly. Some questions may seem personal or irrelevant to you but they are essential in gathering clues to get the best outcome for your Bioresonance therapy.

You may contact us by filling in this form any time you need professional support or have any questions. You can also fill in the form to leave your comments or feedback.

Name*

Address

Street Address Street Address Line 2 City State / Province / Region Postal / Zip Code Country

Phone

Date of Birth

Email*

Occupation

Marital Status

Subject*

Do you have a heart pacemaker?

Yes

Do you have any metal implants?

Yes

Do you have a hearing aid?

Yes

Women - Are you pregnant?

Yes

Have you had a transplant?

Yes

What is your reason for Bioresonance?

When did your symptoms first begin?

What was the initial cause?

What makes it worse?

What makes it better?

How are your energy levels?

Great

Okay

Fluctuating

Poor

Do you have a high point during the day?

Yes

Do you have a low point during the day?

Yes

Do you sleep well?

Yes

Do you drink tea or coffee?

Yes

Do you smoke?

Yes

I am female

Yes

Any pregnancy or birth complications? (ask mother if possible)

Yes

Were you a ceasarean delivery?

Yes

Not sure

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

Unusual course of childrens didease or complications from vaccinations?

Yes

Any serious or recurring disease?

Yes

Psychological issues, traumatic or unsettling experiences?

Yes

Accidents (including sports accidents)?

Yes

Surgeries and other invasive procedures?

Yes

Recreational drug use? (past or present, no matter how small)

Yes

Please indicate if any of your family members have or have had any of the following. Allergies?

Yes

I don't know

Multiple Choice

Yes

I don't know

Arthritis?

Yes

I don't know

Chronic fatigue diabetes?

Yes

I don't know

Parasites?

Yes

I don't know

Tuberculosis?

Yes

I don't know

Hepatitis?

Yes

I don't know

Cancer?

Yes

I don't know

Hypo/hyperthyroidism?

Yes

I don't know

Epilepsy?

Yes

I don't know

Seizures?

Yes

I don't know

Additional comments

Marie Reynolds is a celebrated Wellness & Skin Health Expert in the UK. Her approach to client consultation is unique and has led to Marie building a reputation as a progressive skin health practitioner who deals not only with the visual and physical causes of skin problems, but also the mental thought patterns that have a direct effect on how our skin acts and behaves.