• COVID 19
  • Home
  • What is Vega Testing
  • Organ Screening Form
  • Food Screening Form
  • About
  • Testimonias from clients
  • PSYCK-K®
    • More about PSYCH-K®
  • Pricing and appointments
  • Contact
  • INTAKE FORM
KIM BARZILAY, NHC .... QUANTUM HEALING ....VEGA TESTING, COMOX VALLEY, BC


intake form for new clients, please print and fill out for your appointment​ or one will be emailed to you before your appt as well.
*BEfore your appt please stay hydrated and please no caffiene immediately beforehand*
Also if you have had any medical procedure that required sedation please do not book your appointment within 24 hours of this *


KIM BARZILAY, NHC            VEGA TESTING - INTAKE FORM
 
CLIENT NAME:______________________________________________________            DATE:______________________
Parent/guardian name (if child):_________________________________
Signature of parent/guardian:______________________
Address:_____________________________________________________________________
​Postal Code:____________
Phone Number/ Cell:______________________________­­­ Text:  Y / N      Home/Work:____________________________                   
Email:_________________________________________________________     I would like to receive a newsletter:  Y / N
Birth year:___________________                Gender: _________   prefer not to answer___________
OCCUPATION:­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­­______________________________________________________________________________________
FAMILY PHYSICIAN:________________________________________________________________________________
All information is confidential.  Answer only what you wish to reveal in your health assessment.  Use back of form if needed.
Medical History:
What brings you to my office?_________________________________________________________________________________________
Are you currently under treatment with any other health practitioner?      Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you on any medications from your doctor or any drug store products?  Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Are you taking supplements:   Y / N
LIST:________________________________________________________________________________________________________________________________________________________________________________
Do you have a pacemaker:  Y / N    Are you pregnant: Y / N                                     
Do you have any known allergies: Y / N
                        LIST:______________________________________________________________________________________
                       
How do you react:_____________________________________________________________________________________
How would you rate your stress:        None   /    Slight    /     Moderate    /     Severe
What are your health goals______________________________________________________________________________________
How did you hear of my service:  Family  /  Friend  /  Newspaper  /   Facebook  /  Website  /   Referral  Who:____________________________
The Vega Test is not intended as a replacement for standard methods of evaluation, but as a complimentary tool to help assess any imbalances in your body.  This tool does not eliminate the necessity and effectiveness for a physician’s exam, blood tests, x-rays, or other diagnostic means.  The information obtained from the Vega Test is a piece of your overall health picture.   Thank you for your time.
SIGNATURE:_______________________________________________________________________________
Powered by Create your own unique website with customizable templates.
  • COVID 19
  • Home
  • What is Vega Testing
  • Organ Screening Form
  • Food Screening Form
  • About
  • Testimonias from clients
  • PSYCK-K®
    • More about PSYCH-K®
  • Pricing and appointments
  • Contact
  • INTAKE FORM