SCIO CLIENT DATA BEFORE APPOINTMENT

Name

Email*

Contact Number*

Current address*

Where did you hear about SCIO?*

Where did you hear about me?*

Birth Place*

Birth Date*

Appointment Date*

Number of Organs Removed

Number of Synthetic drugs Using

Number of smokes / day

Number of Steroid type drugs in last year

Number of Street Drugs used in last month

Number of Metal amalgam fillings current

Number of known allergies

Number of unresolved mental factors

I am Responsible for my Body 1 – 10

1

2

3

4

5

6

7

8

9

10

Amount of Processed Foods & Fats in diet 1-10

1

2

3

4

5

6

7

8

9

10

Personal Stress Factor 1-10

1

2

3

4

5

6

7

8

9

10

Number of cups of coffee/tea /day

1

2

3

4

5

6

7

8

9

10

Number of Sugar Type Products / day

Number of 20min + Exercise sessions / week

Number of Alcoholic drinks/day average

Number of extreme exposures to radiation/chemicals/year

Number of major injuries / operations

Number of major infections

Number of glasses of water / fruit juice /day

How many kgs are you overweight

If there is an dis-ease in your body which you would like us to focus on please write detail here.

If you wish to set an intention for the session, please think about it and give it to me at our appointment or write it in now.

Submit