Full Name_________________________________________ Today’s Date __________________Appt. Date ___________________

Address ____________________________________________________________________________________________________

Preferred Phone ________________________ (cell or home ) Alt. Phone _____________________ (cell or home )

Email Address _______________________________________________________________________________________________

Marital Status ________________________ Date of Birth __________________________Gender ___________________________

Place of Birth (City, State) _____________________________________________________________________________________

Height/Weight __________________ Occupation __________________________________ Hours of work per week ____________

Children (Names, Ages) _______________________________________________________________________________________

Please list ALL your known ALLERGIES; Food, Drugs, Animals, Insects, etc.

___________________________________________________________________________________________________________

Emergency Contact/Phone/Relationship __________________________________________________________________________

Previous Health History

Have you ever been bitten by a tick? _______________________ If yes, when did it occur? ________________________________

Did you see a bullseye rash? _________________ Did you receive a formal diagnosis of Lyme disease? ______________________

Have you had any major illnesses? If so, explain __________________________________________________________________

__________________________________________________________________________________________________________

Have you ever had a major injury, fall or auto accident? If so, please explain ____________________________________________

__________________________________________________________________________________________________________

List any other health issues/hospitalizations ______________________________________________________________________

_________________________________________________________________________________________________________

Surgical Procedures

Date Procedure Notes

____________ _________________________________ ______________________________________________________

____________ _________________________________ ______________________________________________________

____________ _________________________________ ______________________________________________________

New Client Health Form

Current Health Status Check the following conditions that apply to you, past and present. Add comments for clarification as needed.

Circulatory/RespiratoryAnemiaBruise EasilyDizzinessShortness of BreathFaintingExcessive bleedingPace MakerWater RetentionCold Hands/FeetCold SweatsChillsSwollen AnklesHigh Blood PressureLow Blood PressureVaricose VeinsBlood ClotsHigh CholesterolHeart ConditionsChest Pain/TightnessIrregular HeartbeatAsthmaCough FrequentlyCoughing BloodWheezingSleep ApneaOther _________________________

EyesVisually ImpairedCataractsGlaucomaDry/Itchy EyesWatery EyesBloodshot/Puffy EyesEye InfectionsNight BlindnessLight SensitiveOther _________________________

HeadHeadaches: Frequency _____________Migraines: Frequency ______________ DepressionAnxiety/WorryForgetfulness/Memory LossBrain FogConfusionDifficulty ConcentratingFeverTrauma/ConcussionOther ___________________________

Ears/Nose/ThroatHearing Difficulty/LossExcessive Ear WaxRinging in Ears

Ear Infections Allergies Sinus Issues Nosebleeds Canker Sores Mouth Corner Cracks Dry/Chapped Lips Sore/Red/Cracked Tongue Bad Breath Dry Mouth Metallic Taste Bleeding Gums Grinding Teeth Difficulty Swallowing Sore Throats/Strep Tonsillitis Clears Throat Often Cold Sores/Herpes Other ________________________

Gastrointestinal Abdominal Pain Indigestion Bloating Belching/Gas Heartburn/Reflux Ulcers Nausea/Vomiting Irritable Bowel Constipation/Diarrhea Dark or Black Stool Undigested Food in Stool Excess Mucous in Stool Anal Itching Hemorrhoids Gall Bladder Issues/Removal Other_________________________

Female PMS Irregular Menstruation Pregnancy Current Previous Fertility Concerns Pelvic Inflammatory Disease Endometriosis Fibrocystic Breasts PCOS Abnormal Discharge Menopause Symptoms Hysterectomy Decreased Libido Other________________________

Male Erectile Dysfunction Prostate Problems

Blood in Semen Low Testosterone Low Sperm Count Decreased Libido Other ________________________

Musculoskeletal Headaches Joint Stiffness/Swelling Spasms/Cramps Strains/Sprains Neck Pain Upper/Mid Back Pain Low Back Pain Shoulder/Neck/Arm/Hand Pain Hip/Leg/Foot Pain Chest/Rib Pain Numbness/Weakness Problems Walking Jaw Pain/TMJ Tendonitis Bursitis Loss of Strength Osteoporosis Curvature of Spine Bone/Joint Discomfort Other________________________

Nervous System Numbness/Tingling Bell’s Palsy Tremors/Twitches Chronic Pain Sleep Issues Herpes/Shingles Seizures Chronic Fatigue Other________________________

Skin/Hair/Nails Acne Dry/Rough Skin Scaling on Scalp Scaling on Elbows/Knees/Feet Rashes/ Eczema Hives Skin Tags Brown Spots Itchy Skin Warts/Moles Cuts Heal Slowly Dry/Course Hair Hair Loss Nail Fungus Nails Weak, Ridged or Split Nail Spots Other________________________

Urinary Painful Urination Nighttime Urination Difficulty Urinating Blood in Urine Urinary Tract Infections Bedwetting Bladder Leakage Bladder Infections Yeast Infections Kidney Infections Kidney Stones Lower Back Pain Other ________________________

OtherAutoimmune IssuesLoss of AppetiteExcessive AppetitePicky EaterInability to Lose WeightInability to Gain WeightBlood Sugar IssuesExtreme FatigueHot/Cold IntoleranceGoutThyroid IssuesRestless Leg Syndrome

Infectious Disease_________________

________________________________

Congenital/Acquired Disabilities______

Other ___________________________

Comments:_______________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

________________________________________________________________________________________________________

_______________________________________________________________________________________________________

________________________________

_______________________________

Please list your major health concerns, listing the most important concern first. Indicate when symptoms began.

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Were there any significant events happening in your life at the time symptoms began? ____________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

List any therapies you have tried for the above concerns and their effectiveness.

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Are you currently experiencing pain? If so, where? ________________________________________________________________

Is the pain chronic? _________________ When did it begin? ________________________________________________________

Would you be interested in receiving information on an FDA-approved electrotherapy medical device that could be purchased and used at home, that would relieve chronic pain and many other medical conditions? Yes ____ No ___

Current Medications Name Date Started

_______________________________________________________________________ _________________________________

_______________________________________________________________________ _________________________________

List any vitamins, herbs or nutritional supplements you currently take, including the Brands ________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

Females

Are you currently pregnant or planning to become pregnant? ________________________________________________________

Are you currently breast-feeding? ______________________________________________________________________________

Are you experiencing menopausal symptoms? If so, what? __________________________________________________________

_________________________________________________________________________________________________________

Males

Do you experience frequent urination? If so, day or night? _____________ Do you have testicular pain/swelling? ______________

Last PSA evaluation ________________________________________________________________________________________

Lifestyle Indicate your current level of stress from 1-10 (1 = no stress, 10 = severe stress)

Reason for stress___________________________________________________________________________________________

Indicate your energy level: 1 = lowest and 10 = highest

How many days per week do you exercise (fun, sweaty activity)?

1-2 days a week 3-4 days a week

5-6 days a week I do not exercise

What type of activity do you do? ________________________________________________________________________________

Do you drink coffee? If yes, how may cups/day? ___________________________________________________________________

Do you drink soda? If yes, how many ounces/day? _________________________________________________________________

How many ounces of water do you drink daily? ____________________________________________________________________

What type of water do you drink?

Reverse Osmosis

Tap Water

Well Water

Spring Water

Distilled Water

How many hours of sleep do you get per night? ___________________________________________________________________

Typical Day’s Diet – include time meal/snack is usually eaten; be as specific as possible with your description (including brands and

liquids).

Breakfast:

__________________________________________________________________________________________________________

Lunch:

__________________________________________________________________________________________________________

Dinner:

__________________________________________________________________________________________________________

Snacks:

___________________________________________________________________________________________________________

Do you have food cravings? If so, what? __________________________________________________________________________

What are your top 5 favorite foods? ______________________________________________________________________________

What foods do you dislike? ____________________________________________________________________________________

How many eliminations per day or week? _________________________________________________________________________

Do you drink alcoholic beverages? If yes, how many per week ________________________________________________________

Do you use tobacco or smoke? If yes, what type and amount per day ___________________________________________________

Did you ever use tobacco or smoke? If yes, for how long and when did you quit? _________________________________________

Do you enjoy outdoors activities? If so, what? _____________________________________________________________________

What do you like to do for fun? ________________________________________________________________________________

How many hours a week do you spend with family/friends? __________________________________________________________

Do you participate in spiritual enrichment? If yes, what? ____________________________________________________________

Is there any other information you would like to share relevant to your current health situation?

__________________________________________________________________________________________________________

_________________________________________________________________________________________________________

What is your level of commitment to address any underlying causes of symptoms (5 = 100%)

Who referred you for your appointment? ________________________________________________________________________

Disclaimer

The Qest4 Bio-Energetic Testing System provides a completely non-invasive method for gaining valuable information about your body’s vital functions. The primary objective of the screening is to disclose patterns of stress and provide feedback that will assist in developing a program to restore each system and meridian to balance.

• I understand that Carol DeLucca is not a medical doctor. I fully understand that this consultation is not for medical diagnostic purposes or treatment procedures. The services performed are at all times restricted to education on healthy lifestyle, intended for the maintenance of the best possible state of natural health and do not involve the diagnosing, treatment or prescribing of remedies for disease. I will be offered information and education on nutrition, food supplements, herbs and better health practices.

• I understand that this New Client Health Form does not provide medical diagnosis and that the testing technician may recommend further medical testing. If I suspect that I need further medical intervention, I understand I should consult my physician. I give my permission for the testing technician to evaluate the results of the Qest4 scans. I understand in doing so the testing technician will give me information about myself and make recommendations based on the Qest4 screening. I understand that the testing technician will not pass judgments on prescribed medications. Any decision to follow through with the recommended program is my own decision and I hold the testing technician harmless.

• I fully understand that those who counsel me are not medical doctors or licensed medical practitioners or nutritionists and I am not here for any medical diagnostic purposes or treatment procedures.

• I understand that I should continue to see any medical doctors I am currently under the care of, and that any prescribed medications should not be altered without first consulting the prescribing physician.

• Information about the traditional uses of supplements that may create a healthy balance in the body may be discussed. This is not intended to be interpreted as a substitute for a licensed physician’s treatment. Nothing said, done, typed, printed or reproduced by Holistic Energetix, LLC or Carol DeLucca is intended to diagnose, prescribe, treat or take the place of a licensed physician.

• The intent is to provide educational information for the purpose of assisting me with lifestyle changes necessary to regain and maintain an environment needed to produce a healthy, balanced body.

• I am not on this visit, or any subsequent visit acting as an agent for the federal, state, county, local law enforcement or news media on a mission of entrapment or investigation.

• I understand that all information and conversations will be kept confidential, and that information regarding my health can be released to another health professional only with my written consent.

• I understand that the Qest4 Bio-Energetic screening will only identify energetic imbalances and does not diagnose any diseases in the body. The balancing item refers to energetic frequency needed to restore balance to the body. Balancing items are defined differently from medical terms and are not a cure for any disease.

• I recognize that the Qest4 screening is an unorthodox approach to balancing my health. Being of sound mind, I have chosen this screening to assist in balancing my health of my own free will and in exercise of my constitutional right for the attainment of life, liberty and the pursuit of happiness.

All fees are due at the time of service. I am kindly asked to provide 24-hour notice of cancellation of appointment. Without such notice, I will be charged for the professional time at the regular hourly rate. By submitting this form, you are indicating that you understand and agree to the above information.

By checking “Yes” I agree to the Disclaimer terms for Holistic Energetix, LLC.

Please download the completed form and send as an attachment to carol@holisticenergetix.com