Burns BAX Intake Forms

8/14/2019 Burns BAX Intake Forms

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Evaluation Checklist

We have provided you with a checklist for your evaluation paperwork . Weask that you please be detailed and thorough in completing it. After youhave completed each section please initial w here instructed:

Initial Here Form #1: The BAX 3000 Allergy Elimination SystemHow it Works (2 pages)

Maximized Health Allergy Relief Center

T: 303.462.4476 F: 303.221.2790

Form #2: Intake Questionnaire (5 pages)Initial Here

Form #3: Your First Visit, What to Expect (4 pages)Initial Here

Initial HereBAX Patient Introduction Video(Main video locatedon www.BioVedaofEastCentennial.com... please view theentire video prior to your initial visit)

Thank You!

www.BioVedaofEastCentennial.com


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How Does the BAX-3000 Work?A Better Understanding of Allergy Symptoms and Treatment

Allergies are nothing more than an inappropriate response to something that is perfectly harmless. Your body sees

an ordinary substance as foreign and attacks it sending you into an allergic reaction of red, itchy eyes, a scratchythroat and trouble breathing. It is essentially aneurological error in the body's immune system where it does

anything it can to combat this "bad, foreign" substance. But, this substance is perfectly harmless. What's worse is

now a new association is turned into an engrained pathway in your nervous system which will associate thatsubstance as a foreign object from there on out. It is asubstance/association error that is made and learned by

your nervous system. An example of this is when you eat a normally harmless food and it makes you sick

afterwards (eggs for example). You get sick and you know what happens (no details necessary here). Your bodywill associate the sickness with the food that you ate so that, most likely, even months to years down the road the

sight or smell of eggs will make you nauseous and even a little sick. But eggs are not the problem; it's the incorre

association that your nervous system has made - that's the problem!

How Do You Know What You Are Allergic To?

Each specific allergen has its own specific frequency. Every chemical does its like an electrical fingerprint. Cadander for example has a certain frequency. Dust has a specific frequency that is different than cat dander. These

frequencies plus 100's of thousands of other frequencies of possible allergens are introduced safely into the body

over several sessions. The body is then monitored to see which frequencies cause it to go into allergic reaction.Then a complete list of all the frequencies (allergens) that caused the body to go into allergic reaction is made

giving you a complete list of everything you are allergic to in that particular session. The average person will have

5-20 different allergens.

Why is this New Approach better than the Old Approach?

This new approach to allergy symptoms is very similar to the allergy scratch test and allergy shot treatmentapproach,but with several unique advantages: no chemicals or needles are used, the number of allergens tested

significantly greater, the accuracy of the diagnosis is much higher thereby, increasing the accuracy of the

treatment. And, unlike allergy shots that often have many side effects, this approach is safe even for smallchildren. The best part, this is aneurologically based approach, which means the body has an easier time

accepting it as opposed to needles and medications.

How Do You Fix These Allergy Symptoms Permanently!

In order to eliminate and rid you of your allergy symptoms, each of these frequencies (allergens) will be introduce

back into the body one at a time, each on different days. For example if milk allergies are to be eliminated first

then on session # 1 the computer will introduce the frequency for milk into the body. Then, and this is the best par

as that frequency (allergen) is painlessly introduced into the body the Class II Laser Technology stimulates specifnerve bundles and certain acupuncture points which releases endorphins and

other relaxing, feel good chemicals. So instead of that frequency (milk) causing

you to go into allergic reaction, the laserretrains the nervous systemto respondnormally when you drink milk instead of an upset stomach, runny nose, etc.

This new nervous system pathway permanently replaces the old pathway, like a


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newly formatted computer program, thus permanently ridding you of that specific allergen. Once all the pathway

are retrained for each allergen you can say good bye to allergy pills, shots, and allergy related red, swollen eyes,scratchy throats and runny noses.

A Great Analogy for You to Think About!

We already pointed out that the allergy symptoms and the allergy response is initiated by a learned neurologicalerror, like a bad habit or a bad reflex. Therefore, in order to truly fix the problem at its source we must eliminate

the neurological error. Below are some examples of this principle in action that you may better relate to.

Addressing allergy symptoms, asthma symptoms and food sensitivities with neurological reprogramming using

the BAX-3000 Laser Technology is like:

1. A computer programmer cleaning your hard drive of program errors and reformatting it to run with optimaefficiency and accuracy.

Using the BAX-3000 is like:

2. An electrician that can pin point with great accuracy where the faulty wiring problem is and correct it so ththing that did not work properly can begin working perfectly again.

Using the BAX-3000 is like:

3. A doctor, who instead of treating only the patients symptoms, finds the root cause and treats it directly,thereby granting the patient longer lasting improvement.

After reading this, one must ask

What is the best way to address symptoms related to allergies, asthma, IBS, chronic fatigue, etc? Is it to medicate

the symptoms and leave the patient with a condition that they must learn to live with?

Or, is it to detect and correct the underlying neurological error that is responsible for the abnormal immune system

response, and correct that error with a system of treatment that best matches the actual problem one that is saferand more effective?

The answer is obvious isnt it?

To learn more about the BAX-3000 Laser Allergy System, available in your area exclusively at Maximized Healt

Allergy Relief Center in Centennial, call 303-462-4476. The office is located at 7323 S. Alton Way, Suite Centennial, CO 80112. The web address is www.biovedaofeastcentennial.com.

Call now to schedule your consultation and assessment.


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INTAKEQUESTIONNAIRE

Patient Name: Date:

Address: Date of Birth:

City, State, Zip: Home #:

Email: Mobile #:

Gender (circle one): MALE FEMALE Work #:

Referred By: _____________________ If you were not referred to us, how did you hear about us? _________________

Primary Care Physician: Physicians Phone #:

Patient herby authorizes Maximized Health to furnish a full report regarding your case history and the results of your

treatments to Primary Care/ Referring Physician

____________________________________

Signature

Although your history and symptoms are very important in our analysis of your condition, it is also important for

us that you understand:

We do not treat symptoms or diseases. A symptom is an attempt by your body to tell you something. We will attempt to find the underlying cause. We do not use drugs in this program. There is no single healthy diet that will work for everyone. Just because food is considered healthy, does not mean it is healthy for you. Your diet consists of everything you eat, drink, rub on your skin, or inhale. Our procedures are safe and painless.

Briefly describe the reason for your visit and what you hope to accomplish:

AGE WHEN SYMPTOMS WERE FIRST OBSERVED

Infant (Age 0-2) Child (Age 3-5)

Child (Age 6-12) Adolescent (Age 13-18)

Adult (Age 19-25) Adult (Age 26-40)

Adult (Age 41 and over)

Tell us about your Vaccinations:

Standard Child Vaccinations Vaccinations were not preformed

Adult Vaccinations (Please Describe) ______________________________________________________________________________________________

Military Vaccinations (Please Describe) ___________________________________________________________________________________________

Any other Vaccinations? __________________________________________________________________________________________________________


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Patient Id #__________


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DID YOU SUFFER FROM ANY TYPE OF PHYSICAL, CHEMICAL OR EMOTIONAL TRAUMA JUST

BEFORE YOUR SYMPTOMS WERE FIRST OBSERVED?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

HAVE YOUR SYMPTOMS EVER GONE AWAY FOR ANY PERIOD OF TIME?

__________________________________________________________________________________________________

__________________________________________________________________________________________________

FAMILY MEMBERS WITH SIMILAR SYMPTOMS

Mother Father

Brother/Sister Grandparents

Son/Daughter Spouse

None

FREQUENCY & SEVERITY OF SYMPTOMS

Constant/Chronic with little change Present most of the time

Present part of the time Present rarely

Prevents some normal activities Considerable interference with normal life

Slight interference with normal life No interference with normal life

SYMPTOMS ARE WORSE

Outdoors and better indoors At nighttime

In the bedroom or when in bed During windy weather

During wet or damp weather When the weather changesDuring known pollen seasons In certain rooms or buildings

When exposed to tobacco smoke With yard work, cut grass, leaves, hay or barns

When sweeping or dusting the house In areas with mold or mildew

In air conditioning In fields or in the country

Tobacco smoke bothers me more than anything else

SYMPTOMS ARE BETTER

After shower or bath In air conditioning

Indoors During or after physical activity

After taking antihistamines With allergy shots

What makes you feel better?

__________________________________________________________________________________________________


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ANIMALS, INSECTS AND BIRDS THAT CAUSE SYMPTOMS ON EXPOSURE

Dogs Cats Rodents (mice, guinea pigs, etc.)

Horses or Cattle Rabbits Birds or Feathers

Bees Other

FOOD RELATED SYMPTOMS

Symptoms flare 5-60 minutes after meals Some foods are craved or addictive

The smell or odor of some foods increases symptoms Some foods cause nasal symptoms

Some foods cause swelling of the mouth or tongue Some foods cause rashes or hives

Some foods cause upset stomach or vomiting Some foods cause diarrhea

Symptoms occur with restaurant salad bars or Asian foods Some foods cause headaches

Symptoms occur with any regularly eaten food Some foods cause asthma

Preservatives, additives or food coloring increase symptoms No problem with foods

FOODS THAT CAUSE SYMPTOMS FROM ONE HOUR TO THREE DAYS AFTER EXPOSURE

Eggs Milk Beef

Corn Wheat Soybean

Peanut Pork Fish

Shellfish Orange or other citrus Potato

Tomato Yeast Chocolate

Coffee or Tea Other

None

CHEMICALS THAT CAUSE SYMPTOMS

Insecticides & pesticides Paints & household cleaners

Perfumes & cosmetics Gasoline or automobiles exhaust

Stove or furnace emissions The smell of new fabrics or fabric store

Chemicals in the workplace Laundry detergent

Newsprint Other:

None

WHEN ARE YOUR SYMPTOMS WORSE Year around

January February March April

May June July August

September October November December

MEDICATIONS

Do you take any of the following medications on a regular basis?

Antihistamines (Benadryl, Actifed, Chlortrimeton, Tylenol Sinus, Tylenol Sleep, Dimetapp,Drixoral, Trimalin,

Atarax, Claritin, Allegra, Zyrtec, etc)

Bronchodilators (Albuterol, Ventolin, Proventil, Serevent, or OTSs such as Primatine Mist, etc)

Steroid Inhalers (Asmacort, Flovent, Pulmicort, Beclovent, Aerobid, Advair, etc)

Nasal Steroids (Beconase, Flonase, Nasacort, Rhinocort, etc)


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PLEASE CHECK OFF THE FOLLOWING THAT APPLY TO YOU:

Digestive Track

__nausea & vomiting

__diarrhea__constipation

__bloated feeling__stomach pains or cramps__heart burn

__blood and/or mucous in stools

Ears

__itchy ears__ear aches/ear infections

__drainage from ear__ringing in ears

__hearing loss

__reddening of ears

Emotions

__mood swings

__anxiety/fear/nervousness

__anger/irritability/aggressiveness__argumentative

__frustrated/cries easily

__Depression S

Eyes

__watery or itchy eyes

__red/swollen/itchy eyelids__bags or dark circles under eyes

__blurred or tunnel vision

Head

__headaches

__faintness

__dizziness__insomnia/sleep disorder

__facial flushing

Heart__Irregular/Skipped Heartbeat S

__Rapid/Pounding Heartbeat S

__Chest Pain S

Joints & Muscles

__pains/aches in joints

__arthritis/osteoarthritis__stiffness/limited movement

__pain/aches in muscles__feeling weak/tired__swollen/tender joints

__growing pains in legs

__Psoriatic/Gouty Arthritis S__Rheumatoid Arthritis S

Lungs

__chest congestion

__bronchitis__shortness of breath

__difficulty breathing

__persistent cough

__wheezing

Mind

__poor memory__difficulty completing projects

__difficulty with mathematics

__underachiever

__poor/short attention span

__confusion

__easily distracted__difficulty making decisions

__mild learning Disabilities

Mouth & Throat Thrush

__chronic coughing

__gagging/clearing throat often

__sore throat/hoarse voice/voiceloss

__swollen/discolored tongue/lips

__canker sores__itching on roof of mouth

Nose

__stuffy nose

__chronically red/inflamed nose__sinus problems

__hay fever__sneezing attacks

__excessive mucous formation

Skin

__acne

__itching

__hives/rash/dry skin__hair loss

__flushing/hot flashes

Weight

__binge eating/drinking

__craving certain foods

__excessive weight

__compulsive eating__water retention

General

__frequent illness

__frequent/urgent urination

__genital itch/discharge

__anal itching

Genitourinary

__kidney problems__urinary tract

__bladder__yeast infections

Other Conditions__Autism S

__A.D.H.D. S

__A.D.D. S

__Psoriasis S

__Eczema S__Auto Immune DisorderS

__Chronic Fatigue S

__Multiple Chemical Sensitivities S

__Asthma S

__Congestive Heart Failure S__Severe Diabetic S

__Severe Depression S

__Obsessive Compulsive DisorderS


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Your First Visit, What to Expect...

Welcome to Maximized Health Allergy Relief Center, a BioVeda Health and Wellness

Center. You have taken the first step in experiencing our revolutionary new alternativetherapy for NSRTSM or Neurological Stress Reduction Therapy. Our goal is to provideyou with the right expectations for your care and the information youll need to makean informed decision about whether this therapy is right for you.

Because every individual is unique, we do not have Standard care plans. What wecan do however is set an expectation for your first few visits and the treatment planthat would be implemented based on the severity of your condition and general state ofhealth and wellness.

FIRST VISIT OVERVIEWTime: 60 M inutes

System Balance

Your first visit starts with a System Balance treatment. The System Balance is a generalde-stressor that calms your body allowing us to get the most accurate assessment andsubstance specific stress readings. You must wait approximately 30-45 minutes fromthe completion of the System Balance to the start of the assessment. Upon arriving atthe office, we will start with the System Balance and then complete your PatientMedical History.

Patient Medical History

Its important for us to understand any symptoms or conditions that you may beexperiencing, any medical diagnosis that has been provided previously by your familydoctor, medications you currently use periodically or regularly, any lab tests, surgery orhospital visits youve had recently as well as your family history. This is also the timewhere we set goals for your care and determine what you want to get out of therapy.

Hypersensitivity Assessment

Following a review of your medical history, if appropriate, we will perform theneurological substance specific stress assessment for all items in Group One. GroupOne contains the items that are most often the triggers for the conditions you areexperiencing. This is not an allergy test but an assessment of which substances youare deficient in, which substances your body has trouble absorbing and whichsubstances your body may inappropriately believe are toxins. If it is determined from


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your medical history that the assessment will be too stressful to your system theassessment will not be done and we can proceed directly to treating Group One items.

Care Plan Explanation & Financial Consultation

Following your assessment which will take approximately 10-15 minutes, we will reviewthe results. The Group One procedure is critical for the patient because thesesubstances are typically the underlying cause for most symptoms and conditions.Patients that complete Group One and have known environmental or food allergiesoften experience an elimination of the symptoms without being treated for the specific

allergen. If the symptoms persist a second assessment will be done for Group Two,Three, or Four which target environmental substances and foods. The order ofassessment and treatment of Group Two, Three and Four substances can be alteredbased on your symptoms and known substance sensitivities.

Care Plans are divided into Mild, Moderate and Severe Protocols. The history andassessment dictates which category you fall into based on which substances as well as

how many substances require therapy.

LASERSM TherapyTime: 5 Minutes

LASERSM is the acronym for our proprietary Light and Sound Energy Relaxationtechnique. Following your first visit, each ensuing visits therapy time will be 2-3minutes during which the laser will be applied down your back and along your allergymeridians. Additional time is allotted for short discussion about your experience andsymptomatic relief.

Each therapy session will focus on a single group of substances. You may visit theclinic every other day for therapy. You may not eat for 1 hour prior to therapy and wesuggest you schedule your therapy so you can avoid the foods and substancesnecessary for the conditioning process to work, please refer to Items to Avoidhandout. Many patients come in the afternoon or on a day off so they can go homeand get a good nights sleep and avoid places with strong odors, chemicals and foods.While most patients feel nothing and experience no side effects following therapy, somepatients do report a tingling sensation, slight sinus congestion or slight redness anditching. These are good signs that the therapy is working and part of the bodys

detoxification process. This usually lasts no more than a few hours.

**** Same as cash financing for 12 months is available with approved credit


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T: 303.462.4476 F: 303.221.2790

www.BioVedaOfEastCentennial.com

I f you rece ive a t rea tment on the f i rs t v i s i t :

You may not shop for eight hours after the visit. So please shop in advance of

your visit.

You may not go to a restaurant for eight hours. (for any reason)

You may not visit a hair salon, barber shop, or nail salon for twelve hours after

being treated.

You must avoid all chemicals for twelve hours, so please refuel your automobile

before your visit.

You may not bathe or shower for eight hours after treatment, so please shower

before your visit.

Do not chew gum, use breath mints, drink anything except water or eat anything

after arriving for your visit.

Not permitted for twelve hours after treatment: Chiropractic Adjustments,

Massage, Acupuncture, Vigorous Exercise, Hot Tub, Sauna, Steam Room or

Swimming. These things should be done before your visit, not afterwards.

You may not consume alcohol for twelve hours after treatment.

Do not eat a large meal after treatment.

You may be given a list of additional things to avoid for 24 hours after treatment.

The res t r i c t i ons above are designed fo r the w ors t c ase scenar io .

We have designed these suggestions based on years of practical experience. You may beable to break some or all of the rules and do just fine, or you may bend one rule and have

to repeat the visit. You will have the best chance for success if you follow all the

suggestions. The restrictions are to be followed for 24 hours, a small price to pay for a

long term benefit.

Burns BAX Intake Forms

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