Please provide the following contact information:

First Name
Last Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Home Phone
FAX
E-mail

Please enter your date of birth and place of birth

Who referred you?

Number of organs removed, including teeth

How many prescription drugs do you use?

How many cigarettes/cigars do you smoke per day?

Number of steroid type drugs used in last year?

Number of street drugs used in past month

How many different allergies?

What is bothering you emotionally or mentally (depression, anger, anxiety?)

On a scale of 1-10, how responsible are you for your health?

How much fat is in your diet? (2-low, 3-medium, 4-high)

Your negativity level (from 1-10)

What is your personal stress level (from 1-10)

Do you take vitamins daily?

How many sugar type products do you have a day (soft drinks, ice cream, etc...)

How many exercise sessions of 20 mins or more a week?

On average, number of alcoholic drinks per day

Number of cups of coffee or tea with caffeine per day

Number of extreme toxic exposures per year (radiation, insecticides, chemicals)

What major injuries have you had in the past (major car accidents, falls, surgery)

Number of major infections (past and present)

How many glasses of water do you drink a day?

How many pounds overweight, if any

How do you feel today on a scale of 1-10 (lowest to highest)?

Quantum clients are encouraged to continue taking their prescriptions and to consult with their physicians on medical matters. Quantum should be seen as a complement to traditional medicine.