Name:       

Address:    

City:          

State/Province:                Zip/Postal Code:
           
Home Phone:

Work/Cell Phone:

Birth date:

Time of Birth:

Birthplace: City/State

Email Address: (please check for accuracy)

EPFX Initial Questions

# Organs Removed: (all teeth = 1)
# Prescription Drugs
# Cigarettes smoked per day
# Steroid Drugs
# Metal Fillings
# Street Drugs
# Allergies
# Unresolved Mental Factors (greed, resentment, anger, etc.)
0 1 2 3 4 5 6 7 8 9 10 I am responsible for my body: 0=no 10=yes
% Fat in Diet (average is 45%)
0 1 2 3 4 5 6 7 8 9 10 Personal Stress None=0  Max=10
# Sugar products per day
# Exercise sessions per week (20 minutes+)
# Alcoholic beverages per day
# Caffeine products per day
# Extreme Toxic Exposures per year (chemo, radiation, etc.)
# Major Traumatic Injuries in life (mental, emotional, physical- accidents, etc.)
# Major Infections
# Glasses of Water you drink per day
# Pounds you feel overweight

Please indicate any areas of interest for the QX session:

Personal History:

Referred by:

Please note: We are not medical doctors, and, as such, by law, we cannot diagnose, treat, cure or prevent any psychological disorder or disease. For more information, please refer to our Terms and Conditions below.