First Name *

Last Name *

Email *

Street Address

Country/Region

City

Postal code

Mobile phone number

Biological Gender *

Date of birth (click on year and month to change) *

Do you have a heart pacemaker?

Yes

Do you have a hearing aid?

Yes

Any metal implants?

Yes

Have you had a transplant? If yes describe the implant

Yes

Have you had bioresonance before?

What’s your primary reason for seeking bioresonance?

When did this first begin?

What was the initial cause?

What makes it worse?

What makes it better?

Do you have a low point during the day?

Yes

Do you have a high point during the day?

yes

Do you drink tea or coffee?

yes

Do you sleep well?

yes

Do you smoke?

yes

Do you drink alcohol?

Yes

Signs / Symptoms

General problems, tick all that apply

The The following things can affect one’s health, even long after they are over, list which apply

1. Any pregnancy or birth complications (ask your mother if possible)

Yes

Not sure

2. 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

Not sure

3. Unusual course of children’s diseases and complications from vaccinations

Yes

Not sure

4. Any serious or recurring disease

Yes

5. Psychological issues, traumatic or unsettling experiences

Yes

6. Accidents (including sports accidents)

Yes

7. Surgeries and other invasive procedures

Yes

8. Recreational drug use (past or present)

Yes

Your close family’s medical history: Please indicate if any of your family members have or had any of the following conditions:

allergies

Yes

Not sure

heart disease

Yes

Not sure

parasites

Yes

Not sure

arthritis

Yes

Not sure

chronic fatigue diabetes

Yes

Not sure

tuberculosis

Yes

Not sure

hepatitis

Yes

Not sure

cancer

Yes

Not sure

hypo/hyperthyroid

Yes

Not sure

epilepsy

Yes

Not sure

seizures

Yes

Not sure

Additional things you wish to tell us

Signing this form indicates that you are voluntarily and with full knowledge willing to undergo a procedure referred to as BioResonance Therapy (BRT). This is a form of modern bioenergetic science. Treatment is based on bio-physics (the physics of life processes), a field of study in German and British universities that has not yet been widely applied in medicine. The human body is seen as a sea of energy. This energy is made up of electromagnetic fields consisting of physical oscillations (waveforms). These oscillations control body processes and different cells send and receive oscillations at specific frequencies (wavelengths). Neurophysiology is one area where this is recognised and many hospitals use EEG instruments, which measure “brain waves” for diagnosis. BRT is therapy with oscillations received by the BICOM instrument either from the body or from substances, such as viruses or allergens. The BICOM instrument picks up signals from the body through applicators and returns them in a modified form. Pathological oscillations can be ‘inverted’ through a mirror circuit to reduce or even eliminate their harmful effect. The aim of BRT is to re-establish the body’s ability to regulate itself. Allergy treatment requires abstention from some foods for a few weeks. Possible reactions are tiredness and headaches but these symptoms usually subside after a short time. As the procedure involves only the measurement of changes in the energy flow of the body with a sensitive meter, it is completely safe. The only sensation normally felt is the pressure of the electronic probe against the surface of the skin. The use of a print out recording the results makes this procedure extremely fast. At no time will the technician state or imply a client should discontinue taking any medication as prescribed by his or her physician. At no time will there be any implied or stated indication to any client to discontinue care under the direction of another physician. This procedure is not intended, implied, or stated to take the place of any conventional medical test or diagnostic procedure. At no time can this office guarantee to resolve a current health concern, however, it has been found that client compliance to the complete recommended therapy usually results in greater and more consistent changes towards better health. This office reserves the right to dismiss any client at any time due to poor compliance with the practitioner’s recommended program. I have fully read and understand the above information, the elements of my informed consent, my rights and responsibilities, and hereby give consent to the BioResonance Therapy procedure. By using this form you agree that will store the questionnaire results for our meeting with you. You can request its deletion at any time.

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