38.107.191.90

Name:       

Address:    

City:          

State/Province:                Zip/Postal Code:
           
Home Phone:

Work/Cell Phone:

Birth date:

Time of Birth:

Birthplace: City/State

Email Address: (please check for accuracy)

SCIO Initial Questions

# Organs Removed: (all teeth = 1)
# 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.)
# Major Infections
# Glasses of Water you drink per day
# Pounds you feel overweight

Please indicate any areas of interest for the QX session:

Personal History:

Referred by:

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