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New Customer Form

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First Name

Last Name

Date of Birth

Place of Birth

Phone

Occupation

Sex Male Female Other

Emergency Contact

Emergency Contact Number

Name of Spouse

Spouse Date of Birth

Number of Organs Removed None 1 2-3 4-5

Number of Synthetic Drugs used None 1 2-3 4-5

Number of unresolved emotional factors (anger, depression, anxiety etc.) None 1 2-3 4-5 6-8 9-12

Number of Children 0

I am responsible for caring for my body 0

Amount of fat in my diet 0

Personal stress in my life 0

No. of sugar type products used in a day 0

No. of exercise sessions in a week 0

No. of alcoholic drinks in an average week 0

No. of caffeine products drunk in a day (coffee, tea, soda) 0

No. of toxic exposures in a year (Radiation, chemicals, insecticides, asbestos) 0

No. of major injuries in the past 0

No. of major infections in the past 0

No. of glasses of water drunk each day 0

How many Kg overweight (1 Kilogram = 2.2 Pounds) 0

Please select if you have had or have AIDS/HIV Yes No Not Sure

Please select if you have had or suffered from Alcoholism Yes No Not Sure

Please select if you have had or have Anemia Yes No Not Sure

Please select if you have had or have Anorexia Yes No Not Sure

Please select if you have had or have Appendicitis Yes No Not Sure

Please select if you have had or have Asthma Yes No Not Sure

Please select if you have had or have a Bleeding Disorder Yes No Not Sure

Please select if you have had or have Breast Lump Yes No Not Sure

Please select if you have had or suffered from Bronchitis Yes No Not Sure

Please select if you have had Bulimia Yes No Not Sure

Please select if you have had or have Cancer Yes No Not Sure

Please select if you have had or have Cataracts Yes No Not Sure

Please select if you have had or suffered from Chemical Dependency Yes No Not Sure

Please select if you have had Chicken Pox Yes No Not Sure

Please select if you have had or have Depression Yes No Not Sure

Please select if you have had or have Diabetes Yes No Not Sure

Please select if you suffer from Epilepsy Yes No Not Sure

Please select if you have had any Fractures Yes No Not Sure

Please select if you suffer from Glaucoma Yes No Not Sure

Please select if you have had or have a Goitre Yes No Not Sure

Please select if you have had or have a Gout Yes No Not Sure

Please select if you have had or have Heart Disease Yes No Not Sure

Please select if you have had or have Hepatitis Yes No Not Sure

Please select if you have had or have a Hernia Yes No Not Sure

Please select if you suffer from Herniated disc Yes No Not Sure

Please select if you have had any Herpes Yes No Not Sure

Please select if you suffer from a High Cholesterol Yes No Not Sure

Please select if you have had or have Kidney Disease Yes No Not Sure

Please select if you have had or have Liver Disease Yes No Not Sure

Please select if you have had Measles Yes No Not Sure

Please select if you have had or have Migraine Headaches Yes No Not Sure

Please select if you have had a Miscarriage Yes No Not Sure

Please select if you have had or have Mononucleosis Yes No Not Sure

Please select if you have had or have Multiple Sclerosis Yes No Not Sure

Please select if you have or have had a Pacemaker Yes No Not Sure

Please select if you have had or have Parkinson's Disease Yes No Not Sure

Please select if you have had or have a Pinched Nerve Yes No Not Sure

Please select if you have had or have a Pneumonia Yes No Not Sure

Please select if you have had or have a Polio Yes No Not Sure

Please select if you have had or have Prostrate problems Yes No Not Sure

Please select if you have had or have a Psychiatric Care Yes No Not Sure

Please select if you have or have had Rheumatoid Arthritis Yes No Not Sure

Please select if you have or have had Rheumatoid Fever Yes No Not Sure

Please select if you have had Scarlet Fever Yes No Not Sure

Please select if you have had a Stroke Yes No Not Sure

Please select if you have had or have Thyroid problems Yes No Not Sure

Please select if you have had or have Tonsilitis Yes No Not Sure

Please select if you have had or have Tuberculosis Yes No Not Sure

Please select if you have had or have Tumour growths Yes No Not Sure

Please select if you have had or have Ulcers Yes No Not Sure

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