Client Information:!!!! Date: Name: Address: Phone: Date of Birth: Age: Gender: M F. Parent/Guardian (if a minor): Phone:

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The Holistic Wellness Center Biomeridian Assessment Statement of Intent: I, Dr. Sandra (Sandi) Queen, am a Doctor of Naturopathy and Educator, not a physician. I do not diagnose or treat a disease. I assist my clients in their desire to support the innate healing response of their body by educating them about individual selection of food, herbs, nutrition supplements, relaxation, and exercise programs. Client Information:!!!! Date: Name: Address: Phone: Email: Date of Birth: Age: Gender: M F Parent/Guardian (if a minor): Phone: Has Parent/Legal Guardian Given Permission for Childʼs Appointment Today? Emergency Contact: Phone: Relationship to Client: Primary Care Physician: Phone: Are you currently under the care of a health professional for any health, medical, or emotional condition? If so, for what problem(s) or condition(s)? DO YOU HAVE A PACEMAKER OR OTHER ELECTRICAL DEVICE INSTALLED IN YOUR BODY? IF SO, YOU ARE NOT A CANDIDATE FOR BIOMERIDIAN ASSESSMENT. DO YOU, OR HAVE YOU IN THE PAST, HAD SEIZURES OF ANY KIND? IF SO, YOU ARE NOT A CANDIDATE FOR BIOMERIDIAN ASSESSMENT. Occupation: Job activities: Hobbies:

Describe a typical dayʼs meals for you, including portion sizes: Breakfast: Lunch: Dinner: Snacks: Circle any of the following consumed, and list how frequently they are consumed: Caffeine Sugar Alcohol Illegal Drugs OTC Drugs Prescription Drugs Fried Foods Grilled Meats White Flour Processed Meats (hot dogs, lunchmeat, bacon) Artificial Sweeteners Artificially Colored Foods Juice/Juice Drinks Dairy Products Do you smoke? If so, how often? Do you use other tobacco products? If so, how often? Are you exposed to second hand smoke? If so, how often? What time to you typically go to sleep? Do you work nightshift? How many hours to you tyically sleep? Do you have trouble falling asleep? Trouble staying asleep? Do you feel refreshed when you awaken? What type of water do you drink (distilled, spring, city tap water, etc.) How much pure water do you typically drink in one day? What is(are) your major complaint(s)? What changes have you noticed with your body? List medications: Any organs or parts removed?

Circle any of the following which you have been diagnosed with or had problems with: Anemia! Cancer! Diabetes Prostate Allergies Rashes Frequent Infections Headaches Edema Heart Attack Stroke High/Low Blood Pressure Dizziness Kidney Disease Liver Disease Menstrual Irregularities Asthma Haitus Hernia Arthritis Hypothyroid Hyperthyroid Autoimmune Disease Fainting Bleeding Menopause Issues High Cholestrol Gastrointestinal Issues Heartburn Numbness Osteoporosis Constipation Diarrhea Indigestion! Other Health Issues: List all physical, emotional, or medical issues youʼve experienced in the last three years: Have any family members within 2 generations had cancer? If so, who, and what kind? In a 25 mile proximity to your home, are there any: (circle any that apply) Landfills High Tension Electric Lines Nuclear Waste Facilities Chemical Plants Gasoline Storage Tanks Areas Sprayed With Pesticides or Herbicides High Traffic Areas Other Areas of Known Toxicity: Do you exercise? If so, how frequently? What types of exercise do you do? List any allergies (food, environmental, etc.)

List any herbal or other supplements, amounts, and how frequently you take them: List any prescription drugs you take regularly, including dosages: Have you had any surgeries or hospitalizations? If so, list when, and what the nature was: I have provided all of my known physical and medical conditions. I understand that the client consultation with Dr. Sandra (Sandi) Queen, ND is for educational purposes only, and not for diagnostic or treatment purposes. I give my consent to participate in this and future consultations, and will not hold Sandra (Sandi) Queen responsible for the outcome of any choices I make resulting from the education I receive during these consultations. I fully understand that Dr. Sandra (Sandi) Queen, ND is not a medical doctor, and is not making recommendations, diagnosis, or other suggestions, nor prescribing any medications or other substances, and that any services or products I choose to incorporate into my lifestyle are due to my own choices. I understand that any information shared in consultations in the offices of The Holistic Wellness Center are not meant to take the place of medical care or treatment for any health or emotional problem or condition, but is soley for the purpose of supporting wellness in my body through the empowerment of education, and any choices that are made are made by myself alone, on my own behalf. Client Signature Date Print Name: If Client is a Minor Child, Signature of Parent or Legal Guardian: Printed Name of Minor: How much time do you spend relaxing: Daily? Weekly? Monthly? What do you do to relax? When taking supplements, I prefer: pills liquids essential oils a variety doesn t matter

Stress Indicators: On a scale of 1 to 10, with 1 being the least and 10 being the most, rate the amount of each of the following stressors. Do not label the stressors from 1 to 10, but rather rate each one individually from 1 to 10. poor quality sleep not enough sleep getting to sleep after 11 PM poor diet exposure to toxins exposure to negativity or anger death of loved one divorce other family stress other lifestyle stress exposure to things to which you are allergic My family life stress is: none minimal moderate severe My relationship stress is: none minimal moderate severe My work stress is: none minimal moderate severe My financial stress is: none minimal moderate severe My physical stress is: none minimal moderate severe My health stress is: none minimal moderate severe Other stress is: none minimal moderate severe I understand that this questionnaire is for educational purposes, and that Dr. Sandra (Sandi) Queen, ND, is not a medical doctor, psychologist, or psychiatrist, and is not making recommendations, but merely educating me for my own interest. I am choosing to order and take any supplements. I understand that, if I am experiencing emotional or mental issues that need the intervention of a licenced professional in this field, Queen Homeschool Supplies, Inc., Dr. Sandra (Sandi) Queen, ND, and The Holistic Wellness Center and all owners and employees recommend that I see a qualified professional instead of, or in addition to, taking this remedy. This remedy is not meant to take the place of professional mental or emotional help. Signature Date PAYMENT IS EXPECTED IN FULL WHEN SERVICES ARE RENDERED. We accept cash, credit card (Mastercard, Visa, or Discover), and, once you are an established customer, we will accept your check in US funds. Returned check fee is $25.00. If you pay by credit card, your credit card statement will read: Queen Homeschool Supplies, Inc., which is the parent company of The Holistic Wellness Center. I understand these terms: Signature Date

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