Pre booking questionaire

To get started, simply take a few moments to fill out this pre-treatment questionnaire to the best of your ability. This helps us tailor our approach to your unique needs. If there’s anything we haven’t asked but you’d like to share, feel free to add it at the end—we’re here to listen.

I've completed the form and am now ready to book a treatment ➚

"If you want to find the secrets of the universe, think in terms of energy, frequency, and vibration" – Nikola Tesla

Your body is energy, your thoughts create frequency, and your healing begins with awareness. Let’s tune in.

Name

First

Last

Phone

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Date of birth

How did you hear about us?

Are you interested in remote or in person therapy

What therapies are you interested in at Inna (Bioresonance, Energetic Scan, Activated Oxygen, one of our supported therapies or not sure!)

Do you know your blood type?

Are you pregnant?

What are your main complaints. List up to 3.

Which other therapies have you already seen regarding these complaints? (Doctor/ naturopath/ other therapists)

Which of these methods has given you relief if any?

Which of the therapies above was not helpful?

Other vaccinations, when? and any other info on this subject.

if not applicable say n/a

Which diseases have occurred (several times) in your family?

Please name the disease or symptom and which family member. if not applicable say n/a

Which operations have you undergone? Tonsils, sinuses, Ears, Gall Bladder, Appendex, Stomach, Kidneys, hernias, wisdom teeth extraction, organ transplant, Cesarean etc) Can you make a note of the approx year or age you were when it took place.

if not applicable say n/a

Any accidents or fractures?

if not applicable say n/a

Any severe illness or infections?

if not applicable say n/a

Any addictions? (medication, drugs, alcohol, nicotine)

if not applicable say n/a

Current medication(s) (e.g. antibiotics, cardiac remedies, blood pressure remedies, cortisone, warfarin, statins etc)

if not applicable say n/a

Any skin diseases, hair loss, skin fungus, thrush, candida etc

if not applicable say n/a

Overseas stays (e.g. India, Africa, South America etc)

if not applicable say n/a

Have you ever had treatment for fungus, parasites, gut health

if not applicable say n/a

Please tell us your history with pregnancies - how many births, have you had any misscarriages or abortions. Did you take the pill, or have the coil fitted etc..

if not applicable say n/a

Do you have any allergies or intolerances - for example hay fever and since when did they start?

if not applicable say n/a

Have you had any significant dental procedures, for example Root canal, tooth extraction, amalgam removal, implants, etc...

if not applicable say n/a

Please let us know if you have any neurological diseases, for example MS, problems with the brain or nervous system, psychiatric diseases. When did they start?

if not applicable say n/a

AUTONOMIC NERVOUS SYSTEM DISORDERS

please move to the relevent number for you. 0 = unsure, 1 = never, 10 = a lot

Increased temperature

Selected Value: 1

Sweating

Selected Value: 1

Night sweat

Selected Value: 1

Easily excitable

Selected Value: 1

Nervousness

Selected Value: 1

Easily fatigued

Selected Value: 1

Concentration problems

Selected Value: 1

Weakness of memory

Selected Value: 1

Dizziness

Selected Value: 1

Weather sensitivity

Selected Value: 1

Headaches? please state where, one side, both sides, when and how often

if not applicable say n/a

CARDIOVASCULAR SYSTEM

please move to the relevant number for you. 0 = unsure, 1 = never, 10 = a lot Give more info when/if relevant

High blood pressure

Selected Value: 1

Low blood pressure

Selected Value: 1

Poor circulation - where?

Vein Inflammations

Selected Value: 1

Varicose veins

Selected Value: 1

Heart valve defect

Myocaridal disease

Heart attack(s)

Arrhythmias

Pain in the heart region

Selected Value: 1

Any further information on the above questions

if not applicable say n/a

HORMONAL DISORDERS

Give more info when/if relevant

Thyroid issues, please state info as necessary

Parathyroid issues, please state info as necessary

Pancreas, please state info as necessary

Ovaries, please state info as necessary

Testicles, please state info as necessary

Pituitary, please state info as necessary

Diabetes, please state info as necessary

Any further information on the above questions

if not applicable say n/a

DISEASES OF THE RESPIRATORY TRACT / LUNG

Give more info when/if relevant

Bronchitis

Pneumonia

Sinustitis

Inflammation of throat/ mouth

Any further information on the above questions

if not applicable say n/a

LIFESTYLE

Please move to the relevant number for you.

Sports

Selected Value: 0

0 = unsure, 1 = never, 2 = rarely, 3 = occasionally, 4 = regularly, 5 = a lot

Which sports?

Any further information on the above questions

if not applicable say n/a

INNER & OUTER ENVIRONMENT

Are there things in your life which you would like to change but are not able to (private life, work, etc)?

if not applicable say n/a

Any further information on the above questions

if not applicable say n/a

DIETARY HABITS & DIGESTIVE HEALTH

Do you eat meat, how often?

Do you eat fruit, how often?

Do you eat vegetable/salad, how often?

Do you consume milk products, how often?

Do you drink coffee, how often?

Do you drink tea, how often?

Do you consume grain products, how often?

Do you eat sugary items, sweets, bakery goods and fizzy drinks?

Can you tell us a little more about your food and eating habits? What is the quality of your food. Do you buy organic or free range. How often do you eat/ how many meals. Do you eat breakfast. And anything else you think is relevant.

How many litres / cups of water do you drink a day? is it filtered, mineralised, tap, distilled etc?

Do you support your diet with any herbs, vitamin and / or mineral supplements? please provide as much detail as you can, how often, name, brands etc

Do you suffer from over acidity?

Do you suffer from constipation - how often?

Do you get wind, how often?

How is your appetite?

Do you belch, how often?

Do you suffer from bloating?

Do you have problems with the liver, gallbladder, Haemorrhoids, or anything else not covered to do with your gut health?

Any further information on the above questions

if not applicable say n/a

SLEEP

How is your sleep? do you fall asleep easily, do you maintain sleep, do you wake up regularly, do you wake up at the same time every night - what time?

if not applicable say n/a

PAIN

Do you have painful diseases of the joints, muscles, soft tissue? Please let us know where the pain is on your body and whether its constant or not. Is there anything that relieves the pain?

GYNAECOLOGICAL / UROLOGICAL DISEASES

Do you or have you suffered from menstruation disorders?

Women only

Do you or have you suffered from painful menstruation?

Women only

Do you or have you suffered from lengthly menstruation?

Women only

Do you or have you suffered from strong bleeding during menstruation?

Women only

Are you struggling to conceive or have any fertility issues? (please answer if this has been the case in the past)

Women only

Do you suffer from pain in the breasts / pectorial?

Do you suffer from discomfort / pain in the kidney area?

Do you suffer from discomfort / pain in the bladder area?

Do you suffer from discomfort / pain / issues with the prostate area?

Men only

Do you suffer from inflammatory diseases?

Do you suffer or suffered from kidney or bladder stones?

Any further information on the above questions

if not applicable say n/a

PSYCHOSOCIAL ENVIRONMENT

Do you feel stressed by the people around you - family members, neighbours, work collegues?

Do you get support, people that you can lean on?

Additional things you wish to tell us

if not applicable say n/a

Please complete the form below

Have you read our t&c's

Please tick once you've read - see bottom of page

Medical Disclaimer for INNA HEALTH LTD

I have read the Medical Disclaimer *

Medical Disclaimer for INNA HEALTH LTD:

1. Purpose of Bicom and BBC2 Systems: The Bicom and BBC2 systems used at INNA HEALTH LTD are designed solely for subtle energy balancing purposes. They are not intended for diagnosing, treating, or curing any medical condition or disease.

2. Consultation and Advice: If you have any doubts or concerns regarding your health, we strongly recommend seeking advice and consulting with your licensed medical doctor.

3. Contraindications: While there are no known contraindications associated with the use of these bioresonance systems, clients receiving balancing sessions are advised to sign a disclaimer as a precautionary measure.

4. Energetic Therapies: It's important to note that energetic therapies, including BioResonance Therapy (BRT), are not recognised by conventional medical authorities. Therefore, specific medical claims regarding the results of these therapies cannot be made.

5. Managing Medical Conditions: It’s crucial for you to collaborate with your designated healthcare provider in handling conditions like hypertension, diabetes, epilepsy, or other medication-dependent ailments during balancing sessions for clients. Clients need to be aware that their medication needs might alter, requiring vigilant supervision in tandem with a healthcare professional.

INNA HEALTH LIMITED will not state or imply that a client should discontinue taking any medication prescribed by their physician. There will be no implied or stated indication for clients to discontinue care under the direction of another physician. And this procedure is not intended, implied, or stated to take the place of any conventional medical test or diagnostic procedure.

6. Hydration and Aftercare: After every balancing session, we recommend clients drink plenty of water over the next 24 hours for optimal results.

Signature

Clear Signature

By checking/agreeing to this form, you confirm that you have thoroughly read and understood all the points above. By doing so, you acknowledge that you are voluntarily undergoing BioResonance Therapy with a complete understanding of its nature and limitations.Your signature indicates that you have read, agreed to, and understood the medical disclaimer and terms and conditions.

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Pre booking questionaire

To get started, simply take a few moments to fill out this pre-treatment questionnaire to the best of your ability. This helps us tailor our approach to your unique needs. If there’s anything we haven’t asked but you’d like to share, feel free to add it at the end—we’re here to listen.

"If you want to find the secrets of the universe, think in terms of energy, frequency, and vibration" – Nikola TeslaYour body is energy, your thoughts create frequency, and your healing begins with awareness. Let’s tune in.

AUTONOMIC NERVOUS SYSTEM DISORDERS

CARDIOVASCULAR SYSTEM

HORMONAL DISORDERS

DISEASES OF THE RESPIRATORY TRACT / LUNG

LIFESTYLE

INNER & OUTER ENVIRONMENT

DIETARY HABITS & DIGESTIVE HEALTH

SLEEP

PAIN

GYNAECOLOGICAL / UROLOGICAL DISEASES

PSYCHOSOCIAL ENVIRONMENT

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"If you want to find the secrets of the universe, think in terms of energy, frequency, and vibration" – Nikola Tesla

Your body is energy, your thoughts create frequency, and your healing begins with awareness. Let’s tune in.