CYMATHERAPY TM BIORESONANCE PAIN/PROBLEM DRAWING
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1 CYMATHERAPY TM BIORESONANCE PAIN/PROBLEM DRAWING Name: Date: Time: Record Number: Directions: on the diagrams below, shade in the areas where you have pain/problem in RED INK.
2 CYMATHERAPY TM BIORESONANCE CLIENT NOTES Name: Date: Time: Record Number: CODE # CODE NAME TIME AREA NOTES
3 CYMATHERAPY TM BIORESONANCE PRIMARY SETTINGS ON BASELINE Name: Date: Time: Record Number: CODE # CODE NAME TIME AREA
4 CYMATHERAPY TM BIORESONANCE BASELINE VISUAL ANALOGUE SCALE Name: Date: Time: Record Number: DIRECTIONS: 1. The following is a Visual Analog Scale. 2. It is rated from 0 (no pain) to 10 (severe pain). 3. Please make a mark on the scale to identify how much pain you have. No Pain 0 10 Severe Pain 1. Is your pain constant? YES NO 2. If your pain is not constant, how long does it last? 3. How many times per day do you have pain?
5 CYMATHERAPY TM BIORESONANCE FOLLOWUP VISUAL ANALOGUE SCALE Name: Date: Time: Record Number: DIRECTIONS: 1. The following is a Visual Analog Scale. 2. It is rated from 0 (no pain) to 10 (severe pain). 3. Please make a mark on the scale to identify how much pain you have. No Pain 0 10 Severe Pain 1. Is your pain constant? YES NO 2. If your pain is not constant, how long does it last? 3. How many times per day do you have pain?
6 HealthHistory Cymatherapy Name: Date: Time: Height: Weight: DOB: Gender: Male Female Address: State/Zip: HomePhone: WorkPhone: CellPhone: E Occupation: Physician: Phone: Location/address: InCaseofEmergencyPleaseNotify: Name: Relationship: Address: Phone: 1.Areyouunderthecareofaphysician,chiropractor,orotherhealthcareproviderforANY reason? YES NOIfyes,pleaselistreason: 2.Areyoutakinganymedications? YES NO Ifyes,pleaselist;usethebackofthispageifmoreroomisneeded. NAMEDOSE/FREQUENCY 3.Doyouhaveanyallergies? YES NO Ifyes,pleaselist: 4.Areyoupregnant? YES NO N/A 5.Doyouhaveanyimplantedmedicaldevicessuchas:aPacemaker/Defibrillator, InsulinPump,orInfusionDevicetodispensepainmedication?
7 6.Hasyourdoctororhealthcareproviderevertoldyouthatyouhaveabone,jointor muscleproblem?ifso,pleaseexplainitinyourownwords. 7.Haveyouhadanysurgeryinthepast? YES NO Ifyes,pleaselist: 8.Haveyoueverexperiencedanychestpainordiscomfort? YES NO 9.DoYOU,orafamilymember,haveahistoryofthefollowingconditions? Heartdisease Heartattack Highbloodpressure Highcholesterol Gout Chestpain(angina) Diabetes AsthmaorShortnessofBreath Otherrespiratoryorheartcondition 10.Doyousmoke? YES NOIfyes,pleasedescribethetypeandamountperday: 11.Doyouconsumealcoholicbeverages? YES NOIfyes: daily weekly occasionally/socially 12.Doyouuserecreationaldrugs? YES NO 13.Pleasedescribeanypastorcurrentmusculoskeletalconditionsyouhaveincurred (i.e.:musclepulls,strains/sprains,fractures,surgery,backpain,orgeneraldiscomfort). Head/neck Upperback Shoulder/clavicle Arm/elbow Wrist/hand Lowerback Hip/pelvis Thigh/knee Lowerleg Ankle/foot 14.Areyouonaspecialdietforanyreason? YES NO
8 15.Doyoutakeanydietarysupplements,multivitamins/herbalEnutraceuticals? YES NOIfyes,pleaselist,usethebacksideofthispageifmoreroomisneeded: 16.Haveyourecentlyexperiencedanyrapidweightgainorloss? YES NO 17.HowmanycaffeineEcontainingbeveragesdoyouconsumeinanaverageday? 18.Doyoufollowanyregularexerciseprogramorsportsactivity? YES NO 19Haveyoueverexperiencedalossoranystressfullifechangingevent? YES NO 20.Haveyoueverbeenavictimofphysicaloremotionalabuse? YES NO 21.Howwouldyoudescribeyourlevelofphysicalactivity? SEDENTARY MINIMAL MODERATE AVERAGE HIGH 22.Howwouldyoudescribetheamountofstressinyourdailyenvironment? MINIMAL MODERATE AVERAGE EXTREME 23.HowwouldyoudescribeyourSleep? Deep Light Restless Howmanyhoursdoyousleep? Doyouwakeupduringthenight? YES NO Ifso,howmanytimes? Whathours? Howdoyoufeelwhenyouwakeup? Alert ReadytoGo Groggy Tired Slowstarting 24.Howwouldyoudescribeyourgeneralmood? veryslightlyornotatallalittlemoderatelyquiteabitextremely cheerful sad angryatself disgusted calm guilty enthusiastic afraid joyful downhearted tired nervous lonely distressed shaky happy excited frightened alone relaxed irritable upset delighted angry atease energetic scared disgustedwithself dissatisfiedwithself Historycompletedby(signature)
9 CYMATHERAPY INFORMED CONSENT Introduction: Cymatherapy isanoneinvasive,soundtherapythathelpsrestorethebodytooptimalhealth, balanceandfunction.itusesadvancedinstrumentstotransmitfrequenciestothebody sorgans andtissuesthatareassociatedwithhealthycellsandhealthycellfunction,supportingthebody s naturalhealingabilities. AcertifiedCymatherapy practitionerselectstheprogramsfortheami750 ortheami1000 to delivertheexactcombinationoffrequenciestobeused.theserelaxingprogramsareapplied transdermally,onthesurfaceoftheskin.cymatherapy administeredbyaqualifiedpractitioneris safe,irrespectiveoftheclient sageorleveloffitness. Cymatherapy isthegroundbreakingworkofdr.peterguymanners,arenowned OsteopathicphysicianfromtheUnitedKingdom,andisanadvancedformofsoundtherapy. Anotherexampleofacousticorsoundtherapyistherapeuticultrasoundtherapybeingusedin rehabilitationtoday. Cymatherapy involvestheapplicationofgentle,audible,soundwithanapplicator/massager appliedtothebodyforanaverageof30to60minutesduringascheduledvisit. Cymatherapy canbeusedsafelyinadditiontoanystandardmedicaltreatmentsprescribedbya doctororotherqualifiedhealthcareprovider. Descriptionofthesession: IunderstandthatCymatherapy involvestheapplicationofgentlesoundtherapywithan applicator/massager,tomybody.iunderstandthattherehavenotbeenanydocumented complicationswiththeuseofcymatherapy. WhileintheCymatherapy program,iagreeto: j Keepmyscheduledappointments, j Completeanyformsusedtoevaluatemyhealth,and j CompleteformsneededtomonitortheresultsofCymatherapy. Risks: Iunderstandthattherisksinvolvedinmyparticipationarethoughttobeveryminimalasno detrimentalsideeffectshaveeverbeenreportedinover50yearsofcymatherapy use.irealize thatthesideeffectsofcymatherapy arethatiwillfeelrelaxedandenergizedandpossiblyiwill experiencereliefofminorachesandpain.therisksoftakingpartinthissessionhavebeen explainedtomeandiamwillingtoacceptthem. IhavebeenadvisedthatifIhaveeitheratemporaryorpermanentpacemakeroranyother implantedmedicaldevicessuchas:apacemaker/defibrillator,aninsulinpump,oranyinfusion2
10 Deviceusedformedication,ImaybeexcludedfromaCymatherapy program.pregnantwomenwill alsobeexcludedfromthisprogram.iunderstandthatiamfreetowithdrawfromhavinganyfuture Cymatherapy sessionsatanytimeafternotifyingmycymatherapy practitioner.ichoosetohave Cymatherapy sessionsundermyownvolition. Confidentiality: Irealizethatmysessionswillbekeptconfidentialandthatmyidentityasaparticipantwillbe availableonlytothepractitionersinvolvedinmycare. Disclaimer: TheAMI750 andtheami1000 areclassifiedbythefdaasacousticmassagers,andregisteredwith thefdaasclassidevices.theseproductsarenotintendedtodiagnose,treat,cureorpreventany disease. Neitherthemanufacturernorthepractitionermakesanyclaimstotheeffectivenessofthese products.theyaresimplyelectricmassagersemittingacoustictones.ifyouarecurrently undergoingmedicaltreatment,itisadvisedyouconsultyourphysicianorhealthcarepractitioner beforeuseofthisoranyacousticelectricmassager. Signatures: Client Date Witness Date Practitioner Date
11 BaselineVisualAnalogueScale Name: Date: Time: SoundModality: DIRECTIONS: 1.ThefollowingisaVisualAnalogScale. 2.Itisratedfrom0(nopain)to10(severepain). 3.Pleasemakeamarkonthescaletoidentifyhowmuchpainyouhave. NoPain0 10SeverePain 1.Isyourpainconstant? YES NO 2.Ifyourpainisnotconstant,howlongdoesitlast? 3.Howmanytimesperdaydoyouhavepain? ********************************************************************************** FollowRupVisualAnalogueScale DIRECTIONS: 1.ThefollowingisaVisualAnalogScale. 2.Itisratedfrom0(nopain)to10(severepain). 3.Pleasemakeamarkonthescaletoidentifyhowmuchpainyouhave. NoPain0 10SeverePain 1.Isyourpainconstant? YES NO 2.Ifyourpainisnotconstant,howlongdoesitlast? 3.Howmanytimesperdaydoyouhavepain? ADDITIONALCOMMENTS:
12 Resources MembersSite:Findmoreinformationandresourcesatwww.Members.CymaTechnologies.com Training:PsychologyofCymawebinartrainingandcertification: SuggestedReading:AmustreadforanyonewhoisinterestedinCymatherapy Formore indepth science,researchandstudies: CymatherapyEAPracticalGuidefor EveryonebyChrisGibbs availableatwww.cymatechnologies.com ClickonTrainingLink Paperbackbookanddownloadoptions. InsidethePhoton:AJourneytowardsHealthdescribesthenewlydiscoveredlayerofbiophotonicsunderlyingall atomicchemistryandbiochemistry.aswiththevarietyofsnowflakes,therangeinbiologicalspecieswithinflora forinstanceisdependentonthisbiophotoniclayerofinteractionwithinatomicandbiomolecularstructures.a newrangeofenergiesthatcanbebalancedonlywithinthebiophotonicstatesareresponsibleforthese innumerablevarietiesofbiologicalspecies. Thephonon,thequantumofacoustic,orvibrational,energyisalsodescribedandgivenstatusalongsidethe photon.hencethe biophonon (sitsasidethebiophotonasanelementwithinbiologicalstructures.soundscan createstructureinthesamewaybiophotonscanusestructuretocommunicate. Antibacterial/Antimicrobialforcleaninggelpads: RadicatefromNeways,(800)998E7232,useID# &makesuretogiveyourshippingaddress.Sprayon papertowelandwipegelpads. NeedLiabilityInsurance?SpecialRateforCymatherapyPractitioners: ABMP(AssociationofBodyandMassagePractitioners)offersliabilityinsurance(andmanyotherbenefits)fora specialratetocymatherapypractitioners.seeabmporganizationformembershipandbenefitsat: thespecialrateforcymatherapypractitioners. PractitionerCommunityForum MoreaboutCymaticsandtheScienceofSound:Cymatics~TheScienceofSound&VibrationalHealing Conference***AnnualFallConferencewww.CymaticsConference.com
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