65 Appendix I Individual Forms Client Information and Release Form 1 understand that ONDAMED is registered with the FDA and classified as a biofeedback class Il medical device. This registration does not allow the device to be used to diagnose or treat diseases, therefore its use is not to diagnose or treat disease, This device allows the practitioner to detect imbalances in the elient’s body by using the pulse feedback method. These imbalances in the body may be related to the complaints and pains being expressed by the client or they may be present and yet ‘unknown to the client, Once the imbalance is discovered, the practitioner may choose one of the ONDAMED’s 173 preset programs, specific client frequencies or microorganism specific frequencies ‘These programs provide gentle, non-threatening low frequencies that are not harmful but which affect aspects of the human physiology, which can be associated with human disease. Itis further understood by me that ONDAMED is a proven therapeutic body regulation system. It works with electromagnetic impulse frequencies, which initiate sel-regulating reactions in the body through induction. The ONDAMED system aims at breaking through normal complaints and to activate the internal regulating centers through impulse frequencies. This methodology is successful because of the action of the electromagnetic impulses and their combination of frequencies and the ability to adjust all of the physical qualities by means of pulse feedback. The puilse feedback method is the best way of stabilizing a client on a specific program and providing immediate control of how the client reacts to the frequency itself. The human body signals exactly what, where and how it requires something. ONDAMED often proves successful where no other biochemical means is able to do so. The procedure for each session is: different frequencies are applied to the client by means of a forceps applicator, then the practitioner holds the clients pulse while scanning the body head to toe and front to back. The vascular autonomic signal (VAS) modulating through the pulse will indicate where the blockages are then stabilized at the time of detection. The neck region presents the most important point of conneetion to the upper and lower control centers of the organism. T understand that with natural healing modalities the client may experience an intial increase in symptoms, or what is known as a healing crisis. This can last from 1 to 4 days and can be similar to flu or cold symptoms e.g. headache, fever, body ache ete. This is recognized as part ofthe healing process. agree not to hold liable for any activities associated with the use of the ONDAMED deviee. The. is responsible for following the guidelines in the ONDAMED Users Manual so as to provide accurate services of which the ONDAMED device is capable of providing. acknowledge that I have been told of the possible risks involved with the ONDAMED system and I have ‘been given satisfactory answers to my questions concerning this procedure and related matters without prejudice. Tacknowledge that | do not have a pacemaker. ‘The ONDAMED device is not currently a usual or customary modality, so therefore most medical insurance providers, including Medicare, do not cover it. Therefore, J agree to be personally responsible for all fees billed to me by 1 have read this informed consent and understand it. Tam not a minor (under 18 years old). Lam here today and on subsequent visits on my own behalf and not as an agent for federal, state or local agencies. Tam not on a mission of entrapment or investigation Name: aie Date: Witness:First Time Evaluation Please complete the following ques 3 carefully. This information will help us to build a customized program personally designed for you. Date: Referred b Name! ‘M_F_Birth date: Age: Address Ci: State: Zip: ‘Oceupation: Height: E ‘Marital Status: No. Children Home Phone: Cell Phone: 1. Complaints ~ please rank your current complaints and rate their severity from 1 to 10, 10 being the most severe 2, Other Information ~ Please add additional information or health concerns 3. Medications ~ Please list all medications you are currently taking and how long you are taking them. Include aspirin, birth contro pills et, 4. Smoking Do you currently smoke? __If yes, how much How long have you smoked? 5. Surgeri ~ What surgeries, operations, traumas, ear accidents have you had? a, Do you have breast itmplants? Other surgical implants? » Have you had elective surgery e.g. fice lift, tummy tuk etc? € Do youhave any meal or plastic inside your body ex, clamps, plates? 4. Do you have any pieced ears or other body piercing? Tattoos? 6. Scars ~ Deseribe any major sears on your body. 7. Siress ~ Please rate your stress level from 1 10 10, 10 being the highest ‘What is the major reason(s) for your stress? K ONDAMED