Please fill out the information on this form about your health,

at least 24 hours prior to receiving treatment

NAME:       

ADDRESS:    

CITY:          

STATE:              ZIP CODE:
             
HOME PHONE:

WORK/CELL PHONE:

BIRTH DATE:

TIME OF BIRTH:

BIRTH PLACE/ CITY & STATE:

Email Address: (please check for accuracy)

EPFX Initial Questions

# Organs Removed: (all teeth = 1)
Please list organs by name.
Names of Prescription Drugs
# Cigarettes smoked per day
# Steroid Drugs
# Metal Fillings
# Street Drugs
# Allergies
# Unresolved Mental Factors (greed, resentment, anger, etc.)
0 1 2 3 4 5 6 7 8 9 10 I am responsible for my body: 0=no 10=yes
% Fat in Diet (average is 45%)
0 1 2 3 4 5 6 7 8 9 10 Personal Stress None=0  Max=10
# Sugar products per day
# Exercise sessions per week (20 minutes+)
# Alcoholic beverages per day
# Caffeine products per day
# Extreme Toxic Exposures per year (chemo, radiation, etc.)
# Major Traumatic Injuries in life (mental, emotional, physical- accidents, etc.)
Life Threatening Infections (ie. Hepatitis, HIV, Malaria)
# Glasses of Water you drink per day
# Pounds you feel overweight

Please indicate any areas of IMPORTANCE for the EPFX session:

Personal History:

Referred by: