PATIENT INFORMATION AND DECLARATION

First Name

Middle Name

Last Name

Phone/Mobile

Enter Date and Time today

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Birthdate

Age

Gender

Weight

Height

CASE DECLARATION

Please select if you have any of these conditions.

Select all that applies

	Yes	No
Any type of Cancer / Lupus / Leukemia, Undergoing Chemotherapy
Scheduled for Surgical Procedure or Operatiom, Biopsy, Angioplasty, Coronary Artery bypass
Hypertension, Cardiovascular / Heart Disease, Stroke, Chest/Nerve Pain, Low/High Blood Pressure, Aneurysm, Epilepsy
Diabetes (Any type), Pancreas / Spleed Problems
Arthritis, Gout, Liver Problem, Kidney Problems, Gall Bladder Problems, Leg cramps, Muscle & Joints Pains and Bones
Skin and Lung Problem - Sinusitis, Primary Complex, PTB, Allergic Rhinitis, Koch's Infection, Emphysema, Eczema, Asthma, Psoriasis, Hormanal Imbalance
Cyst, Myoma, Thyroid disease, Goiter, Lymphoma, Lipoma, Fibrosis Lymphoma, Lymph Nodes, Polyp, Tumor, Prostate Enlargement

Other Disease Please specify:

Avoid or lessen the intake of the following:

	Yes	No
Fatty & Oily food
Sweets from refined sugar and MSG
Processed & Canned Products
Junk food / Chemically-treated food
Excessive intake of dairy products
Caffeiene from choco, tea, cola & coffee
Alcoholic drinks/ Smoking
Salty food
Acidic food
Carbonated Drinks / Soda
Fish without scales (kaliskis)
Fruits with sap / resin (dagta)
Nuts & Beans
Fishy (malansa) such as: Patis, Bagoong, Hipon, Pusit, Alimango / Alimasag, Talangka, Itlog at Manok

Disclaimer

Zynergia and Health Forum developed these nutritional guidelines to assist in providing the basic natural habits required to improved health. They are not intended to diagnose, treat or assure healing. All decisions concerning the care of oneself are made solely by the concerned individual or his/her health care team carefully reflecting on all aspects of the person's specific health situation. The above guidelines are the easist and fastest way we know that will lead a person to lasting health as guided by naturopathic rules. Following them is done with full agreement and willingness to trust nature's ability to heal.

WAIVER OF LIABILITY & RELEASE

In consideration for being allowed to participate in HEALTH FORUM, I release from liability and waive my right to sue Zynergia Health & Wellness Corporation and Health Forum, Inc., which organizes and operates Health Forum and their employees, officers, volunteers and agents (collectively "Health Forum Team") from any all claims, including Health Forum Team's negligence, resulting in any physical injury, illness (including death) or economic loss that I may suffer because of my participaton in this Activity, including any travel to and from the Activity.

I am 18 years or older, I have read this document, and I am signing it freely. I understand the legal consequences of signing this documents, including

a.) Releasing the Health Forum Team from all liability,
b.) Waiver of my right to sue the Health Forum Team, and
c.) Assumption of all risks of participating in this Activity, including travel to and from the Activity.

I understand that this document is written to be as broad and inclusive as legally permitted by the laws of the Republic of the Philippines I agree that if any portion is held invalid or unenforcable, I will continue to

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