Orders – Chayyim Centre

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Name
Username*
First Name*
Last Name*
Nickname
Ocupation*
Contact Info
Email Address*
Phone (Including country code)*
Required phone number format: (###) ###-####
Address*
Date of Birth*
Place of Birth*
Do You Know Your Time of Birth?*
- Yes
- No
Time of Birth:
Do You Have a Pacemaker?*
- Yes
- No
Religion/Belief System*
Current Symptoms You Wish to Work With*
Known Allergies*
Any Other Information I Should Know*
Referred By*
Password*

Minimum length of 8 characters.
The password must have a minimum strength of MediumStrength indicator
Repeat Password*
DISCLAIMER
1. I Fully understand that the attending therapists are not allopathic doctors (M.D’s) and do not pretend to be, but are (in the context of the SCIO biofeedback system) nutritional, wellness consultants working with the biofeedback technology.
2. I fully understand the difference between the practice of allopathic medicine, nutritional wellness consulting, and Biofeedback.
3. I fully understand that the services provided by the attending therapists are NOT allopathic, but are nutritional, behavioral or biofeedback in nature.
4. I fully understand that the attending therapists perform their services within the parameters of natural health care and wellness system using biofeedback and stress reduction.
5. I fully understand that the attending therapists do not offer allopathic drugs, surgery or chemical stimulants or radiation therapy. I understand that illness is not being diagnosed nor treated and that information that may assist with my wellness and stress reduction are being measured.
6. I have solicited the attending, biofeedback therapist’s services in good faith, exercising my freewill and following the dictates of my own conscience which allows me to select what I understand is most beneficial to my health.
7. If I desire any services not provided by the attending, biofeedback therapists, which is my prerogative, I fully understand that I should seek them elsewhere.
8. I presently seek counsel, advice, opinions, biofeedback or points of view and/or programs within the scope of the attending therapist’s wellness and stress reduction practice. I am aware and release the biofeedback technician to do biofeedback tests and treatments.
9. I fully understand that the SCIO Biofeedback System services provided by the attending therapists are not generally accepted and/or recommended by allopathic doctors or other conventional health practitioners.
10. I fully understand and accept the fee to be paid.
Disclaimer Agreement*
- I Agree
Section A
Number of organs removed (include tonsils, appendix, gall bladder and wisdom teeth)*
Number of synthetic drugs used currently*
Amount of cigarettes smoked per day*
Number of steroid type drugs used in the last year*
Number of metal amalgam fillings*
Number of street drugs used per month*
Number of all know allergies (which cause anaphylactic shock or hives)*
Mental disease*
- Yes
- No
Number of unresolved feelings (anger, greed, desire, sadness, resentment, fear, etc)*
I am responsible for my body (value out of 10, 1 being the lowest, 10 being the highest)*
Number of sugar type products consumed per day. (include soft drinks, ice cream, etc)
Number of exercise sessions per week 20 minutes or more. (Not work)*
Number of alcoholic drinks per day on average*
Number of tea, coffee or any other drink containing caffeine*
Number of toxic exposures in the last year to:
Radiation*
Insecticide*
Chemicals*
Number of major injuries in the past (car accident, operation, broken bones, etc)*
Number of major infections in the past and present*
Number of glasses of water per day (metric)
How many kilos would you like to lose?*
Height in cm.*
Weight in kilograms*
Waist circumference in cm*
Thigh Circumference in cm*
PLEASE ATTACH A FULL BODY PHOTO OF YOURSELF IN A BATHING SUIT*
Personal stress (value out of 10, 1 being the lowest, 10 being the highest)*
IF YOUR VALUE IS 7 OR HIGHER, PLEASE FILL IN SECTION B.
Section B
Please indicate your value out of 10, 1 being the lowest, 10 being the highest.
Problem with bowels
Problem with sweat
Problem with urine
Problem with mucous
Problem with menstruation
Problem with breath
Problem with skin
Problem with sleep
Problem with interpersonal stress
Job or school stress
Struggle with self or money
Stress from sickness
Family stress
Stress from the desire for things to be different
How many times a day do you meditate or use stress reduction techniques?
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Disclaimer

The SCIO system is to be used as a Biofeedback Multimedia System. It is designed for stress detection and stress reduction. No claims are made of the SCIO system or its results and nothing that the SCIO Practitioner does, diagnoses or treats any illness or disease nor replaces any other treatment. Please consult your family medical doctor for the diagnosis or treatment of disease. Please also consult your family medical doctor before undertaking any health program.

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