Personal Medical History
(Ionic Detox)
01
Name
02
Mailing Address
03
Personal Info
04
Medical History
05
General Health Info
06
Lifestyle Habits
07
Terms of Service
Full Name
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Address
Your email address
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Birth Date
Height
Weight
Age
Gender?
Male
Female
Cell Phone
Home Phone
Emergency Contact Name
Emergency Contact Phone
Referred by:
How did you hear about us? (Search engine, Ad, Coupon, etc.)
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Why have you chosen to have a IONIC DETOX FOOTBATH?
Do you suffer from? (Check all that apply):
Fibromyalgia
Insomnia
Poor Mental Clarity
Fluid Retention
Muscular Injuries
Low Vitality/Low Energy
Arthritis Pain
Hepatitis A, B, C
Slow Healing
Poor Circulation
Chemotherapy Cleanse
Yeast & Candida
Acidosis
HIV Positive/AIDS
Other reason for treatment
Are you currently under a Physicians care?
Yes
No
Reason for Physician care
Are you pregnant?
Yes
No
Any other medical condition? (HIV Positive, Hepatitis A, B, or C, etc.)
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Terms of Service
Body Balance System is not recommended for pregnant or nursing mothers, persons with pacemakers, implanted organs, epilepsy or open wounds on the feet. Body Balance System is a product of Lifestream Medical Corporation. The product is not intended to treat or diagnose any medical condition but is provided for you in your own research about bioactive frequencies and the desire to eliminate toxins and heavy metals from the body. These devices are pending FDA approval, so no medical claims are made. Any BBS device is a service to you and does NOT imply or can be construed as medical advice, diagnosis or a SELF-HELP prescription for any individual or any specific health condition. I have not been diagnosed with any symptoms from the above disclaimer for my Ionic Foot Bath session. I am aware that therapists are not physicians and therefore do not diagnose or prescribe. If I experience any discomfort or pain, I will notify my therapist immediately and /or stop the session. This facility does not claim to cure or treat any condition or disease.
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