Body Electrician is a private membership association. Free membership is essential before checkout

Health Analysis Form

FORM INSRUCTIONS

Before you begin, please take a moment to review how to correctly fill out the form below. This will help ensure that your health analysis is as accurate as possible.

Fill Out For Yourself Only

You must complete this form for yourself only. The only exception is for minor children. For children under 18, a parent or legal guardian must fill out the form on their behalf.

Submitting Your Picture

For accurate analysis, it’s essential to submit a clear photo following these guidelines:

Make sure your head and shoulders are fully visible.
Face the camera with one or both palms visible, ensuring that they are open and facing forward.
Use a solid-colored background to avoid distractions

Answer All Questions

Answers all questions honestly and to the best of your knowledge.

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PERSONAL INFORMATION

IMPORTANT: You must complete this form for YOURSELF ONLY. The only exception is for minor children. For children under 18, a parent or legal guardian must fill out the form on their behalf.

First Name *

Last Name *

Send us your photo; *

Drop your file here or click here to upload Upload 1 Photo Of Yourself with head, neck, shoulders up, at least 1 palm facing camera, and solid background color

Please upload a photo of your head and neck (shoulders up) with one or both palms facing the camera. Ensure the background is a solid color. Do not compress the file.

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Email *

Phone *

Date of Birth *

Gender *

Male
Female

Height (Ex: 5'7" or 5ft 7in) *

Weight (lbs) *

Occupation *

How long at this occupation (years) *

HEALTH INFORMATION

List your FIVE main concerns or complaints regarding your health: *

List your known health issues / disabilities / diagnosis: *

List any Hospitalization / Surgery / Accidents, etc. List age at the time and outcome of the event *

List current use of Prescriptions / Over the Counter drugs / Alternative supplements, herbs, etc. *

Are you currently under care of any other practitioner? Please describe: *

Is there anything else you would like us to know? *

MEMBERSHIP AGREEMENT

Membership in our Body Electrician Private Membership Association is simple and mandatory for doing business with us. This is in order to keep your health issues a matter of your private choice without concern of interference from any authority.