Healing and Wellness with Biomagnetic Therapy Confidential Intake Form: 
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Today’s Date: *
Full Name:
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Full Address:

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Cell Phone #:

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Is it ok to leave a message about your care at the listed phone #?  

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Emergency contact person:
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Relationship to emergency contact person

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Emergency contact phone:
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Primary Care Physician:

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Primary Care Physicians Phone #:
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Other Healthcare Providers and Phone#

What is your Occupation?
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How did you hear about us?
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Please share all issues and/or health concerns you are seeking care for. Include dates of when symptoms first appeared, diagnosis etc. Provide as much detail as possible.

Are you experiencing any pain? If so where?


On a scale of 1-10 rate pain 10 being the highest 
Are you experiencing a lot of anxiety and/or stress past or current?
On a 1-10 scale rate stress:

Do you consume alcohol?  Average # per week? 

Do you smoke tobacco, marijuana or vape?  Average # per week? 

Do you suspect you have had any exposure to mold?

How much water do you drink on average per day?

Do you have any issues falling asleep?

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Do you have any issues staying asleep?

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What time do you go to bed?

How many hours of sleep do you average per night?

How often do you exercise?  What type of exercises?


Any past surgery’s? if so what were they?

Any Dental procedures such as root canals or dental implants?

Do you have a pacemaker or defibrillator?

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Have you ever had chemo?  Last date?

What for?


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Have you ever had a concussion?


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How many?

Are you pregnant or a chance you could be?

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What vaccines did you receive as a child?
Did you have any adverse reactions?
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Have you had any recent vaccines and if so which ones?
Did you have any adverse reactions?
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List ALL prescription AND over the counter medications, including dosages and frequency:
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List ALL vitamins, herbs, or supplements including dosages and frequency:
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What do you typically eat for Breakfast:

What do you typically eat for Lunch:

What do you typically eat for Dinner:

Do you follow any specific diet?
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Do you consume dairy?
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Do you consume wheat/gluten?
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Do you eat fish or Sushi?
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How often?
Do you find yourself craving sugar?
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Do you drink soda or energy drinks?
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How many per day?
Does your stomach hurt after eating?
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Do you feel bloated after eating?
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Do you have a daily bowel movement?
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How many per day?
Did you have any major childhood illnesses?
If yes please list illnesses and age 
Do you have memories of trauma or significant loss as a child? 
If yes describe trauma and what age you were when trauma happened.
Have you been told of having traumatic experiences as a child but have no memory of them? 
Have you had a significant trauma or loss as an adult and if so please explain ?
Have you ever experienced emotional/ physical or sexual abuse as a child and what age?
Have you ever experienced emotional/ physical or sexual abuse as an adult past or current or both?
Did you in the past or are you currently participating in counseling?
Do you own any pets and if so what kinds?
Does your pet/pets sleep in bed with you?
Do you and/or your pet/pets spend time outdoors in grassy areas or in/near the woods?
Has your pet/pets ever been diagnosed with Lyme's, had flees or rabies?
Has your pet/pets had vaccines for rabies and or Lymes? 
Do you treat your pet/pets with flee medication?
Do you use bug/mosquito spray when spending time outside?

REMEMBER: Things to do after a biomagnetic session:

take a detox bath using Epsom salt

do not drink from the same bottle/glass you used prior to the biomagnetic treatment without fully cleaning it with hot soapy water first

replace your toothbrush or soak your toothbrush in hydrogen peroxide for at least one hour

Soak retainers, dentures, partials, or any removable dental appliances in a solution to clean such appliances prior to placing back in your mouth

Maintain a healthy diet

Stay hydrated

Rest and be gentle and good to yourself

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Biomagnetic Therapy Consent of Treatment

It is my choice to receive Biomagnetic pair therapy. I understand that Biomagnetic pair therapy is a homoeopathic treatment and this treatment is being done only to balance the body’s bioelectric systems for homeostasis purposes.

This is non-allopathic medicine and after the biomagnetic treatment you may or may not experience the following symptoms as your body responds to resetting itself and clearing out pathogens: increased urination, fatigue, low grade fever, headache, dizziness, diarrhea, clumsiness, muscular pain and sleepiness. These symptoms if experienced will vary depending on each person. 

It is also possible that the symptoms you experienced before the biomagnetic treatment will possibly feel worse before it gets better as your body moves pathogens out and resets itself. These symptoms can last a few days. If you are concerned about symptoms or think you are having a medical emergency call your doctor or your local health care emergency service immediately.

I understand that I have not been given any guarantees or promises regarding the scan and biomagnetic treatment I am about to undergo, nor will I be given a diagnosis, change or alteration of the prescription medications I am or not currently taking. 

I further understand that a biomagnetic practitioner does not diagnose illnesses or prescribe medical or pharmaceutical treatment. It has been made clear to me that biomagnetic therapy is not a substitute for a medical examination and it is recommended that I contact a licensed healthcare provider for any medical conditions or concerns that I may have. I have provided accurate information concerning all past and current health conditions that I am aware of and I agree to report any changes in my health to my biomagnetic practitioner as they arise. 

I also understand that I should not have a biomagnetic therapy treatment if I am in  the first trimester of pregnancy, have a pacemaker or have had chemotherapy in the past 3–5 years. 

Anyone with a hearing aid should remove the device when receiving a biomagnetic treatment so the magnets do not drain the battery.

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