Step 1 of 4 25% Welcome to Takingcare.co.nz Before we start with your Quantum Biofeedback session we need to know a little more about you.1. Personal DetailsName(Required) First Last Date of Birth(Required) DD slash MM slash YYYY Place of Birth(Required)Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City State / Province / Region Postal Code / ZIP Country 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 Occupation(Required)Gender(Required) Male Female Other Emergency Contact(Required)Emergency Contact Number(Required)Relationship(Required) Single Married Divorced Widowed Relationship Separated Who were you referred by?Head and Shoulders PhotoPlease upload a head and shoulders photo of yourself. The biofeedback machine requires this to accurately diagnoses and treat. Ideally this should be a current photo showing only your head and shoulders. The file must be less than 5MB.Accepted file types: jpg, gif, png, Max. file size: 5 MB. 2. Medical History Part 11. Rate your happiness (from 1 to 10, 1 = least, 10 = most)(Required) 1 2 3 4 5 6 7 8 9 10 2. Number of organs removed(Required) None 1 2-3 4-5 3. Number of synthetic drugs used(Required) None 1 2-3 4-5 4. Number of times you smoke per day(Required) None 1 2-3 4-5 6-9 10-15 16-20 20+ 5. Number of times you vape per day(Required) None 1 2-3 4-5 6-9 10-15 16-20 20+ 6. Number of amalgam (silver) fillings in your mouth(Required) None 1 2-3 4-5 6-9 10-15 16-20 20+ 7. Number of street drugs currently used each month(Required) None 1 2-3 4-5 6-9 10-15 16-20 20+ 8. Number of known allergies(Required) None 1 2-3 4-5 6-9 10-15 16-20 20+ 9. Number of unresolved emotional factors (anger, depression, anxiety etc.)(Required) None 1 2-3 4-5 6-8 9-12 3. Current Lifestyle1. I am responsible for caring for my body (from 1 to 10, 1 = least, 10 = most)(Required) 1 2 3 4 5 6 7 8 9 10 2. Amount of whole food plants in diet (from 1 to 10, 1 = least, 10 = most)(Required) 1 2 3 4 5 6 7 8 9 10 3. Amount of fat in my diet (from 1 to 10, 1 = least, 10 = most)(Required) 1 2 3 4 5 6 7 8 9 10 4. Personal stress in my life (from 1 to 10, 1 = least, 10 = most)(Required) 1 2 3 4 5 6 7 8 9 10 5. No. of sugar type products used in a day (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 6. No. of exercise sessions in a week (from 0 to 10 or more)(Required)(Each session being 20 minutes or more.) 0 1 2 3 4 5 6 7 8 9 10 10+ 7. No. of alchoholic drinks in an average week (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 8. No. of caffeine products drunk in a day (coffee, tea, soda) (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 9. No. of toxic exposures in a year (radiation, chemicals, insecticides, asbestos) (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 4. Medical History Part 21. No. of major injuries in the past (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 2. No. of major infections in the past (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 3. No. of glasses of water drunk each day (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 4. How many kg overweight (1 kilogram = 2.2 pounds) (from 0 to 10 or more)(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 5. Number of Children(Required) 0 1 2 3 4 5 6 7 8 9 10 10+ 6. Please select if you have had or have AIDS/HIV(Required) Yes No Not sure 7. Please select if you have had or suffered from Alcoholism(Required) Yes No Not Sure 8. Please select if you have had or have Anemia(Required) Yes No Not Sure 9. Please select if you have had or have Anorexia(Required) Yes No Not Sure 10. Please select if you have had or have Appendicitis(Required) Yes No Not Sure 11. Please select if you have had or have Asthma(Required) Yes No Not Sure 12. Please select if you have had or have a Bleeding Disorder(Required) Yes No Not Sure 13. Please select if you have had or have a Breast Lump(Required) Yes No Not Sure 14. Please select if you have had or suffered from Bronchitis(Required) Yes No Not Sure 15. Please select if you have had or have Bulimia(Required) Yes No Not Sure 16. Please select if you have had or have Cancer(Required) Yes No Not Sure 17. Please select if you have had or have Cataracts(Required) Yes No Not Sure 18. Please select if you have had or suffered from Chemical Dependency(Required) Yes No Not Sure 19. Please select if you have had Chicken Pox(Required) Yes No Not Sure 20. Please select if you have had or have Depression(Required) Yes No Not Sure 21. Please select if you have had or have Diabetes(Required) Yes No Not Sure 22. Please select if you suffer from Epilepsy(Required) Yes No Not Sure 23. Please select if you have had any Fractures(Required) Yes No Not Sure 24. Please select if you suffer from Glaucoma(Required) Yes No Not Sure 25. Please select if you have had or have a Goitre(Required) Yes No Not Sure 26. Please select if you have had or have Gout(Required) Yes No Not Sure 27. Please select if you have had or have Heart Disease(Required) Yes No Not Sure 28. Please select if you have had or have Hepatitis(Required) Yes No Not Sure 29. Please select if you have had or have a Hernia(Required) Yes No Not Sure 30. Please select if you suffer from Herniated disc(Required) Yes No Not Sure 31. Please select if you have had any Herpes(Required) Yes No Not Sure 32. Please select if you have had any Covid viruses(Required) Yes No Not Sure 33. Please select if you have had any Covid vaccinations(Required) Yes No Not Sure 34. Please select if you suffer from High Cholesterol(Required) Yes No Not Sure 35. Please select if you have had or have Kidney Disease(Required) Yes No Not Sure 36. Please select if you have had or have Liver Disease(Required) Yes No Not Sure 37. Please select if you have had Measles(Required) Yes No Not Sure 38. Please select if you have had or have Migraine Headaches(Required) Yes No Not Sure 39. Please select if you have had a Miscarriage(Required) Yes No N/A 40. Please select if you have had or have Mononucleosis(Required) Yes No Not Sure 41. Please select if you have had or have Multiple Sclerosis(Required) Yes No Not Sure 42. Please select if you have had or have a Pacemaker(Required) Yes No Not Sure 43. Please select if you have had or have Parkinson's Disease(Required) Yes No Not Sure 44. Please select if you have had or have a Pinched Nerve(Required) Yes No Not Sure 45. Please select if you have had or have Pneumonia(Required) Yes No Not Sure 46. Please select if you have had or have Polio(Required) Yes No Not Sure 47. Please select if you have had or have Prostate problems(Required) Yes No Not Sure 48. Please select if you have had or are having Psychiatric Care(Required) Yes No Not Sure 49. Please select if you have had or have Rheumatoid Arthritis(Required) Yes No Not Sure 50. Please select if you have had or have Rheumatic Fever(Required) Yes No Not Sure 51. Please select if you have had Scarlet Fever(Required) Yes No Not Sure 52. Please select if you have had a Stroke(Required) Yes No Not Sure 53. Please select if you have had or have Thyroid problems(Required) Yes No Not Sure 54. Please select if you have had or have Tonsilitis(Required) Yes No Not Sure 55. Please select if you have had or have Tuberculosis(Required) Yes No Not Sure 56. Please select if you have had or have Tumour growths(Required) Yes No Not Sure 57. Please select if you have had or have Ulcers(Required) Yes No Not Sure 5. Additional Information1. Other Medical Conditions2. Family HistoryPlease indicate if any family member have had any of the following medical problems, and if so who? Diabetes, Heart Disease, Hypertension, Hepatitis/Liver Disease, Stroke, Cancer, Alcohol problems, Congenital problems, Mental/emotional problems?3. Health Concerns and ObjectivesDescribe any health concerns and your objectives in seeking wellness services with Taking Care
