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IMPORTANT NEW CUSTOMER INFORMATION, PLEASE FILL AND SUBMIT BELOW!

CONTACT INFO

Date of Intake Assessment (MM/DD/YYYY)

First Name

Last Name

Cell

Office Phone

Fax

Birthday

**To select your birth year, click on the current year located above the calendar.**

Time & Place of Birth

Occupation

Address

Address 2

City

Zip Code

Country

Referred By (Please enter full name)

Emergency Name & Contact Number

INTRODUCTION

Our questionnaire is designed to get to know you and better understand your goals and desires for using Biometech products. The more information you provide, the better we will be able to customize your program to fit your needs.

What results do you want to achieve most from using BiomeTech products?

What is your definition of health and/or wellbeing?

How do you measure success?

HEALTH

Which of the following do you consume regularly:

Alcohol - If yes, how often?

Caffeine: Coffee or Tea - If yes, how often?

Chocolate - If yes, how often?

Carbonated / Sports / Energy Drinks - If yes, how often?

Sugar - If yes, how often?

Artificial Sweeteners - If yes, how often?

Processed Food - If yes, how often?

Fast Food - If yes, how often?

Gluten (wheat, rye, barley) - If yes, how often?

Marijuana / CBD Oil - If yes, how often?

Cigarettes / Vape Pen - If yes, how often?

Recreational Drugs: Yes / No - If yes, which ones, how often?

Prescription Medications: Yes / No - If yes, which ones, what dosage, how often?

Have you ever taken the following medications:

Accutane - Yes / No

Larium - Yes / No

Retin-A - Yes / No

Fen Phen - Yes / No

Steroids - Yes / No

Benzodiazepines - Yes / No - If yes, which ones, what dosage, how often?

WELLNESS

Do you sleep through the night?

Do you have trouble waking up?

Is your energy stable or do you experience ups and downs throughout the day?

On a typical day, what would you say is your general disposition: joyful, sad, irritated, frustrated, angry, tired, energetic, anxious, disconnected, stressed, other?

WELLBEING

Have you ever been exposed to any major chemicals - such as: pesticides, environmental cleaners, etc.?

Have you ever lived near or do you live near an industrial plant, or around agricultural environments?

Have you experienced trauma or loss? If so, please share.

Do you now, or have you suffered from depression? If so, please share

Have you ever experienced PTSD? If so, please share.

Have you ever experienced a head injury, concussion, or suffered from a Traumatic Brain Injury?

GOALS & DESIRES

Please answer the following questions. Go as in depth as you feel comfortable:

How would your life be different if you had the body, health, and wellbeing you dreamed of?

What would you like to change right now regarding your health and wellbeing?

What are your physical, mental, and emotional goals?

Do you feel financially and professionally secure?

What gives you a sense of purpose and meaning in life? What role, if any, does "spirituality" play in your life?

Imagine what it would be like to truly change your habits. What would dramatically improve in your life?

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We at BiomeTech believe it is every person’s divine right to live in Prosperity- Emotionally, Financially and Health-fully. In this way, we can work in partnership to improve your health.

By signing and initialing below: You, the client, understand that when beginning this program and making changes in your nutritional and/or dietary habits, you may experience a period of detoxification. If symptoms arise and you need assistance with your spray program or if you have questions, please call our office for assistance.

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Possible Detoxification Symptoms Could Be:

Irritability, restlessness, fatigue, listlessness, bad dreams, bloating, nausea and flu like symptoms.

You may also experience a release of repressed emotions such as anger and sadness.

These are normal Detox Symptoms and they will pass as you continue you program.

Please also note that this information and any accompanying printed material is not intended to replace the attention or advice of physicians or other healthcare professionals. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with a qualified health care professional.

DISCLAIMER *The statements made regarding these products have not been evaluated by the Food and Drug Administration. The efficacy of these products has not been confirmed by FDA-approved research. These products are not intended to diagnose, treat, cure or prevent any disease. All information presented here is not meant as a substitute for or alternative to information from healthcare practitioners. Please consult your healthcare professional about potential interactions or other possible complications before using any product. The Federal Food, Drug, and Cosmetic Act requires this notice.*

Please Initial here:

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Full Name

Signature

Signature Date (MM/DD/YYYY)

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BiomeTech 2554 Lincoln Boulevard Suite 306, Venice, California 90291

Phone: 310.822.3801 FAX# 310.305.7287

SUBMIT

Thank You For Completing This Form. All Information Is Confidential.