Intake form

The Portal to
Your Well-Being

Harmonise yourself from within using colours, sounds, vibrations, and energy resonance.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Intake Form

All new clients are asked to complete a detailed history prior to their first visit. This helps determine the best form of treatment. Please fill out the form below before your first appointment.

Your data is protected! We believe your data is your property and support your right to privacy. Your data is not shared with 3rd parties.

*First name (required field)

*Surname (required field)

Date of Birth

Height

Weight

Work

*Mobile (required field)

*Email (required field)

Street and house/flat number

City

Postcode

Emergency Contact

Relation

Phone

Relation status

Spouse/Partner Name:

# of Children

Occupation

Do you enjoy your job?

Yes No

Primary Reason for seeing us:

Have others helped you with the problem:

What are your expectations after the sessions:

Who can we thank for your being here (who referred you):

Check the conditions listed below which you have experienced:
Select P for over a year ago, C for current or leave blank if not applicable

METABOLISM

Weight Gain

Weight Loss

Heigh/Low Blood Pressure

Blood Sugar

Thyroid

DENTAL

Tooth Problems

Root Canals

Amalgam Fillings

Difficulty chewing

TMJ

DIGESTION

Heartburn

Abdominal Pain

Gas/Bloating

Diarrhea

Constipattion

Blood in Stool

History of Ulcers

Colitis

Liver Desease

FEMALE

Pregnant

Problems with periods

Cancer

Breast Tenderness

Breast Implants

Menopausal Symptoms

SKIN

Rash

Eczema

Dry Skin

Acne

Recent Botox

Any recent substance Injection under skin

CHEST

Chest Pain

Palpitations

Cough

Shortness of Breath

Asthma

URINARY

Frequent Urination

Difficulty starting Urination

Urinary Incontinence

STRUCTURAL

Arthritis

Bursitis

Osteoporosis

Foot/Ancle Swelling

Blood Clots/Phlebitis

Varicose Veins

Recent Surgery

Neck Pain/Problems

Back Pain/Problems

Sciatica

EYES/EARS/MOUTH

Headaches

Dizziness

Ringing in Ears

Blurred Vision

Sinus Problems

Difficulty Swallowing

Mouth Sores

NEUROLOGIC

Numbness or Tingling

Weakness

Insomnia

Poor Balance

MALE

Prostate

Cancer

ALLERGIES

Medications

Chemicals

Foods

Plants

IMMUNE

Chronic Fatigue

Fibromyalgia

Yeast Infections

Past Viral Infections

Past Strep or Mono

Epstein-Barr

Lyme

Medications, Herbs, Supplements (list name, dose, and purpose)

We recommend drinking 2.5 - 3.5 liters of water daily starting on the day before your first session and for the days of integration.

Do you expect any difficulty with this?

Yes No

Explain:

How much do you use per week?

Alcohol

Tobacco

Coffee/Tea

Drugs/Marijuana

Injuries/Accidents?

Yes No

When & Describe

Traumatic life events leading to any illness:

Toxic Exposures:

Describe other medical conditions that we should be aware of:

Other:

Areas in body of complaint or tension:

Surgeries with dates (include location of metal plates/rods/screws)

Other

Current Pain Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Stress Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Current Energy Level (1=very low, 5=very high): 1 2 3 4 5 Explain:

Describe any specific medical attention or assistance you will need while visiting our center (you must be able to get into the unit or bring a caregiver to help you).

Will you be bringing a caregiver, nurse or spouse with you?

What brings you joy?

Please check the box of the most emotional draining relationship or relationship in your life:

Is your home environment peaceful or stressful most of the time?

Do you have trouble concentrating, or ‘brain fog’?

Yes No

Do you feel supported?

Yes No

What drives you, inspires you, gives you a sense of purpose:

Please check the emotions that best reflect how you feel most of the time:

Do you adhere to any particular diet?

How many hours of sleep do you get on average?

Do you drink filtered or purified water?

Yes No

Describe your exercise/activity routine:

Are you sensitive to light / loud noise?

Yes No

If Yes, Please explain:

Do you consider yourself a highly sensitive person (HSP) ?

Are you in fear regarding your health?

Regaining well being requires a strong personal commitment. How ready are you to make the lifestyle changes, the diet changes and the attitude changes that may be necessary to good health?

Ready Somewhat Not looking to make changes

FAQS →

Questions? You Will Find Many Answers Here.

What to Expect →

Our advice & Protocol For Sessions & Our Promises

Advanced Energy Therapy

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Location

Van der Oudermeulenlaan 1,
2243 CR Wassenaar
Ground Floor
Free parking
Wheelchair accessible

PRIVACY / TERMS

CONTACT US

Disclaimer: The statements made or services provided through this website or by the Company are not intended to diagnose, treat, cure or prevent any disease. Testimonials regarding the technology are voluntarily given and do not represent the opinions of the Company. The services provided by the Company are not intended to be a substitute for professional medical advice, diagnosis, or treatment.

MADE WITH ❤︎ BY GL

BOOK NOW

Intake form

The Portal to
Your Well-Being

Harmonise yourself from within using colours, sounds, vibrations, and energy resonance.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Intake Form

Check the conditions listed below which you have experienced:
Select P for over a year ago, C for current or leave blank if not applicable

Visit our page →

FAQS →

News & Advice →

What to Expect →

Advanced Energy Therapy

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Location

CONTACT US

BOOK NOW

Intake form

The Portal to Your Well-Being

Harmonise yourself from within using colours, sounds, vibrations, and energy resonance.

Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Intake Form

Check the conditions listed below which you have experienced: Select P for over a year ago, C for current or leave blank if not applicable

Visit our page →

FAQS →

News & Advice →

What to Expect →

Advanced Energy Therapy

Breakthrough Resonant Chamber Technology for Better Health and State of Mind. Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Location

CONTACT US

The Portal to
Your Well-Being

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.

Check the conditions listed below which you have experienced:
Select P for over a year ago, C for current or leave blank if not applicable

Breakthrough Resonant Chamber Technology for Better Health and State of Mind.
Beneficial Frequencies for Physical & Emotional Pain Relief, Recovery from Illnesses, Stress Level Management, Burn-Out Relief, Immunity & More.