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+31 6 28 73 85 97

Wellness Preparation Formorm

Wellness Preparation Form

Application date

Naam:

E-mail:

Telefoon:

Date of birth

Gender

Madame

Mister

Other

City / Company

Did you undergo any surgeries?

Yes

If your answer is YES, please explain which kind of surgery and year

Have you ever had transplantations or transfusions?

Yes

If your answer is YES , please explain which and year.

Are you pregnant, or are you planning to get pregnant? Are you undergoing any fertility treatment?

Yes

Do you have a pacemaker, or other devices that run on batteries in your body?

Yes

Did you ever undergo chemotherapy, radiotherapy, or cancer treatment ?

Yes

If your answer is yes, please explain what and when.

Do you have any medical condition?

Yes

If your answer is YES, please explain which ones.

Are you under medication?

Yes

You are taking these BMP sessions because:

You have a medical diagnose and need more options to recover

You need to prevent a burnout

You just like to keep a balance with your health

You have several symptoms to take care of

In case you have symptoms or a diagnose, please name them here:

Weight and length

Weight less than 70 kgs

Weight more than 70 kgs

Weight more than 95 kgs

Length less than 170cms

Length more than 170 cms

I declare that I have loyally and sincerely provided specific information about my physical condition and health that may affect the informed process that will be carried out.

Yes

Terms and conditions

I agree with the terms and condition

Thank you for sending your form

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Terms and conditions

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Contact

Contact@mybeinghealthy.com

+31628738597

Address

Maaskanterf 15,

Amersfoort

MyBeingHealthy

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