Pre-Consultation Questionnaire

Welcome to your initial step towards better understanding of your energetic patterns and blockages. Please take a few moments to answer the following questions.

Your responses will provide valuable insights so we can gain perspective on your specific concerns, which allows us to tailor a personalized approach to best serve your needs.

Basic Info Needed
Name
First Last
Current Location
Male or Female
- Male
- Female
Birthday
Month
Day
Year
Age
Weight
Top Three Health Complaints
Please list your top three health concerns with the most pressing first, as well as let us know when these issues started and describe them as best as possible.(Required)
Successful Remedies
What treatments, lifestyle changes, or remedies have you tried in the past that have resulted in improvement of your health concerns? Please also list your current supplement routine if you are on a regularly scheduled protocol so we can keep those in mind when making further recommendations.(Required)
Allergies & Medications
If you have any allergies or are currently taking medication, please list those here.(Required)
Diagnoses & Surgeries
List any previous diagnoses or surgeries you have had, as well as the date these occurred. Do not forget to add any resections (organ removals) if applicable.(Required)
Additional Information
Is there anything else you feel is important for us to know about your health or lifestyle? This could include dietary restrictions, allergies, significant life stressors, or any other information you believe is relevant to your health.(Required)
Disclaimer

We appreciate your interest in our bioresonance testing services. It is crucial for us to communicate that bioresonance testing is not recognized or approved by the U.S. Food and Drug Administration (FDA) as a diagnostic or therapeutic method. The analysis and recommendations provided through bioresonance testing are not intended to serve as a diagnosis or treatment for any disease. Always seek the advice of a physician or other qualified healthcare provider with any questions you may have regarding a medical condition. WellnessPlus and Ariel Welch cannot be held liable for any claims or damages arising from the use or misuse of the information obtained from the Energy Scans.
(Required)
- By checking this box, I consent to share this information with WellnessPlus for the purpose of my upcoming health consultation. I understand that my information will be used to assist in my care and protocol planning, and I affirm that the information provided is accurate to the best of my knowledge.
Signature(Required)
Date July 26, 2024
Please submit this questionnaire as soon as possible, we are unable to run your scan and begin the analysis without it, so the “1 week turnaround time” may be delayed if you do not fill out right away. We look forward to helping you achieve your health goals. .

Pre-Consultation Questionnaire

Basic Info Needed

Top Three Health Complaints

Successful Remedies

Allergies & Medications

Diagnoses & Surgeries

Additional Information

Disclaimer

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