Advanced Intake Full Name Date of Birth E-Mail Phone Number Optional: This is to have a backup in case there is a problem with your e-mail, and potentially to ask you questions directly if there is an issue with your intake. Occasionally we reach out if there is something surprising coming up during testing. What test are you ordering? Please note that you can change at any time by resubmitting this document with updated information. FreeFirstTest requires no fee whatsoever. Other tests will not be run until both payment and intake are completed, but you can start on your intake even before you have sent payment. FreeFirstTestBasic ChartTriField ChartAdvanced ChartComprehensive ChartDon't know What is your top goal in testing? Describe your purpose with testing more fully. Include a basic backstory of your personal wellness needs. Top symptoms (list five) How did you hear about our testing? Selection Parameters What areas would you like included in your testing? Energy science, EMF sensitivity, biophysicsPersonalized nutrition, supplement useLifestyle, life path issues, life path patterningSpiritual health, mental, transpersonal Protocols Please tell us what protocols you would like us to select from: Nutrition Protocols Allow allAllow food suggestionsAllow herbal protocolsAllow bulk (powdered) vitamin protocolsAllow bulk (powdered) food based, plant extract, and other protocolsAllow organized diet protocolsAllow homeopathyAllow bottled supplements under $35Allow supplements over $35Allow nutrition-related activity suggestions like sauna, enemas, colonics, liver flushes, etc.Allow advanced diet protocols like juicing, fermenting, and other advanced protocols. Environmental Protocols Allow allAllow mindfulness oriented sensory exercise protocolsAllow energetic healing protocolsAllow at home simple laser protocolsAllow tapping and similar protocolsAllow environmental modification design suggestions in line with Building Biology standardsAllow environmental modifications that may require renovationAllow tools to support the home environment (air filter, propolis nebulizer)Allow personal technology use protocolsAllow healing activity protocols (i.e. infrared sauna, time outside, etc.)Allow energetic healing tools built to modify frequency fields Tell us about your experience Lifestyle assessment: Fail to engage in heavy exercise regularlyFail to walk or move for two hours per dayFail to walk or move for thirty minutes per dayDon't have many friendsDrink 3 or more drinks on a regular basisSmoke cigarettesSmoke weedUse other drugs once per month or more (list below)Eat fast foodEat irregularlyDon't sleep on a regular scheduleDon't sleep enoughCan't sleep enoughNot as sensitive to how you feel as you used to beDon't feel wellCan't stand some aspects of your life (please list below)Can't stand some friends or people close to youHave barriers with your family (please list name of people and describe in one sentence the barrier)Unhappy (please write what you feel it is caused by)Resentful of life circumstance (please describe below)Work too muchWork too littleDon't have people in my lifeDon't have the right people in my lifeStressed often (please describe below)Unhappy often (please describe below)Frustrated often (please describe below)Can't connect well with people in my life Additional Lifestyle Notes (anything that comes up to mention) Diet Please check the foods that you eat GlutenOatsDairy, all formsDairy, some formsEggsCornSoyMeat other than fishProcessed meat (bacon, sausage, lunch meat)FishRiceSalt (iodized)Packaged foods with salt in themPre-made meals at home (please describe below)Restaurant foods on a regular basis (Please describe below)Non-organic products, generallyNon-organic products, oftenNon-organic products, rarelyFoods with added sugarFoods with high fructose corn syrupCoffee (2 or more per day)Tea with caffeine (2 or more per day)Energy DrinksDiet food productsMostly low carb foodsMostly low fat foodsMostly raw foodsMostly meat-based foodsMostly plant-based foods Additional diet notes (please elaborate and be specific on all dietary choices you have made) Let's talk about lifestyle. What are the healthiest things you do during the day? What do you think you do that is not healthy? What do you wish you could change but you can't? Let's talk about your goals Describe your top symptoms, in order: What are you most frustrated with with your wellness? What protocols have worked for you and you feel good about? What have you tried that failed? What do you feel good about, but you're not sure if it's working (with protocols)? What do you need help with that you have not yet stated? What illnesses do you know you have, and have had in the past? Please explain pertinent aspects of your dental history, your structural history, any injuries, any scars, and any surgeries. Please describe all of the protocols you are on. List the name and brand of all products with timing and dose. Include medication. Include diet and other protocols. What practitioners are you seeing, and what other therapies not yet listed are you employing? Other information Let's take the photograph Need to do this later? Complete this intake without the photograph, and send it at the photograph upload page. We need a photograph of you (your face), with your eyes closed. You can optionally also send us a full body shot, including below your feet and above your head, with your arms at your sides with palms facing the camera (use a timer on your phone to do this--do not use a mirror for personal photographs). You do not need to do anything special with these photographs, but they should be taken in a place where you normally spend time, and a time where you feel normal or a bit on the not wonderful side. Don’t take photographs after acute illness or injury (while you’re sick), but if you’re feeling not your absolute best, this might help us hone in problems flaring up during such times. On the other hand, don’t take your photograph directly after twelve hours of consecutive healing sessions, or while on a trip to a place you normally don’t spend time, or directly after exercising. These will all bias our results. Upload Instructions The most reliable way to give us access to your photograph(s) is to upload it to a storage service (NextCloud, Google Photos, iCloud, OneDrive, etc.) then share the link with us. Make sure that link sharing is turned on. You can upload multiple folders by sharing the folder they are in, or by uploading them all as a zip file. Upload link to personal photographs Link to photographs of variables for testing If you are sending additional variables (foods for testing, supplements, etc.), please share the link to the folder or zip file where they are contained. For more information on the variables you can and should submit for testing, visit the OMESA Intake Page. Disclaimer Do you agree to all aspects of the following disclaimer? Write your name and check that you accept below. This service is non-medical. Work with a licensed physicians for all cases where you are seeking medical answers, diagnostics, and help. This disclaimer will explain that this is a biometric energy test based on establishing norms for research parameters of energetic reactions inside the cell. This educational test measures how to balance your “biometric energy field” and not your physical health. We are in no way responsible your actions based on this testing or their consequences. A Non-Medical, BioEnergetic Test Why you should order our test Our test evaluates the biometrics of energy. It should not be used for medical examination. Personal Responsibility for Actions The testing provided does not diagnose, treat, cure, or prescribe. You are solely responsible for all decisions and actions you make. Our information is educational only, and it has not been evaluated by the FDA. It is not a substitute for medical advice, diagnosis, or treatment. We do not have any control over how you may choose to use said information, therefore we cannot be held responsible for your actions. You are liable for all ramifications of your actions, including personal injury, expenses, illness, or death. Client confidentiality All client information will be kept confidential. All client information will be released to the client directly. Your information may be used anonymously for research, but at no point will personal names, addresses, or other potentially sensitive information be used. Your information may be released to practitioners you are working with if you give permission. Authorized Representatives and Direct Use Only Clause By ordering this test you agree that the name of the person indicated for testing is the name of the person whose saliva swab was collected. If ordering for someone else, you must note yourself as their authorized representative with legal permission. Non-Research Use Only By ordering this test you agree that it is for personal use only and you are not ordering a research test or using test results for the purpose of research expressed as written scientific writing or other spoken or published information without our knowing consent. Test data may not be published or publicly shared without our permission. Government Agents By ordering this test you certify that you are not working with or for a government agency or working with any agency or lab engaged with observing our test system. On Personal Phone Consultations Your phone counselor may go over information about your personal health with you (such as in intake, or listening to your story), but may not interpret, diagnose, treat, cure, or prescribe based on that information. The purpose of all phone appointments is “energy balance” based on your biometric energy screening. Constrictions of use This test may not be used for medical evaluation. We to not diagnose, treat, cure, or prescribe, nor do we offer information that will assist in diagnosing, treating, curing, or prescribing. Use with your doctor Doctors and other care providers should not use the information from our tests as diagnostic tests or medical evaluation. Full Name I agree to all items of the above disclaimer and by submitting this intake I signify that I have read and understood all portions. If you are filling this out on behalf of someone that you have legal guardianship for, please write their name and your relationship to them in the following box: Submit Δ
