BiomeTech is an exclusive dynamic line of wellness and regenerative products that optimize your personal health by fortifying the microbiome in your body.

The  microbiome is the mechanism that signals your central nervous system (brain) and the enteric nervous system (digestion) to work effectively and optimally. It includes all of your metabolic functions, endocrine functions, autonomic functions, immune functions, and cognitive functions.  The capacity  of a healthy Microbiome influences  every aspect of your life experience. Our goal is to assist you to optimize and maximize the capacity of your microbiome.

So that we are aware of any past and present physical aspects that make you who you are, please take time to complete the following questionnaire.  Each one of these questions has meaning and is being asked for a specific purpose. Please be as thorough as possible.

Our products can be of best service when we have a complete picture of your life, past and present.  And your personal goals– small and large.  Please be open and forthright with your answers so that we may be able to provide you with the utmost support.

Please see below and check all that apply

Please provide further details of any of the conditions ticked above.
Details to include: the condition, age you experienced it, its duration, whether you fully recovered, medicines taken and any additional comments.

Check each substance used

CANNABIS
Marijuana, hashish, hash oil, CBD

CAFFEINE
(Coffee, decaf, tea, yerba mate, kombucha, matcha, green tea, white tea, jasmine tea, black tea, sodas, caffeine pills, energy drinks etc)

SUGAR
(Refined / Processed / List out any sweeteners that you use)

CHOCOLATE
(Cacao, Raw Chocolate)

PLANT & OTHER MEDICINES
(Ayahuasca, Bufo, Kambo, Peyote, Mushrooms, Microdosing, etc)

AMPHETAMINES/OTHER STIMULANTS
(Adderall, Ritalin, Benzedrine, Dexedrine, Vyvanse, Fen-Phen, (Phentermines), etc.)

ANTIDEPRESSANTS
(Celexa, Lexapro, Prozac, Luvox, Paxil, Zoloft, Trintellix, Viibryd, Topamax, Wellbutrin, Ketamine)

BENZODIAZEPINES/TRANQUILIZERS
(Valium, Librium, Halcion, Xanax, Klonopin, call Dan, Diazepam, “Roofies” - GHB)

SEDATIVES/HYPNOTICS/BARBITURATES
(Amytal, Seconal, Dalmane, Quaalude, Phenobarbital)

STEROIDS
(Prednisone, Cortisol, Cortisone,Hydrocortisone, Fluticasone, Celstone, Testosterone, Estrogen, Progesterone, Hormone Replacement Therapy (HRT))

OTHER OPIOIDS
(Tylenol #2 & #3, 282’S, 292’S, Percodan, Percocet, Opium, Morphine, Demerol, Dilaudid)

SEIZURE DRUGS
(Anticonvulsants: Gabapentin, Dilantin, Diazepam, Depakote, Lamictal, Tegretol, Trileptal)

ACNE DRUGS
(Accutane, Tretinoin, Retin-A)

MALARIA DRUGS
(Larium, Chloroquine, Primaquine, Arakoda)

SEXUAL DRUGS
(Viagra, Cialis, Flibanserin, Addyi)

HALLUCINOGENS
(LSD, PCP, STP, MDA, DAT, mescaline, peyote, mushrooms, ecstasy (MDMA), nitrous oxide)

INHALANTS
(Glue, gasoline, aerosols, paint thinner, poppers, rush)

ANTIBIOTICS
(Cipro, Gemifloxacin, Levaquin, Norfloxacin, Tetracyclines, Fluoroquinolones, Doxycycline, Azithromycin, Trimethoprim, Amoxicillin)

Other Substance Use (Please specify)

Surgery/major accidents or hospitalizations
Please list details of any past, recent or scheduled surgery, major accidents or hospitalizations.  Details to include: Type of surgery, your age at the time, reason for surgery, any complications, broken bones, traumatic brain injury, concussions etc.

Exposure to Major Chemicals
Have you ever been exposed to any major chemicals such as pesticides, environmental cleaners, mold, cosmetic chemicals etc? 

Farming
Did you grow up near a farm or near a chemical factory?

Eating Disorders
Have you ever had or do you currently have an eating disorder (anorexia nervosa, bulimia nervosa, binge eating disorder, ARFID)?  If so, please give your age when it started and when it finished and if you sought treatment for it or are currently receiving treatment.

Rehabilitation Facility
Have you or a family member attended a rehabilitation facility for treatment?  If so, please list as many details as possible. What treatment or treatments was/were being received and the date and length of time of the treatment(s) and if it was a family member please provide their relationship to you.

Relationship History
What is your current marital status? ex. Single, Married, Divorced, Separated?  If you have been married more than once, please provide in detail the number or marriages along with the details of the length of time of those marriages.  If you are separated or in the process of a divorce, please provide as many details as you can. For example, how long you have been separated, where are you in the process of your divorce, is it amicable or is it hostile?

Family Health History
Include all blood relations as far back as you can go and as far sideways! Any illnesses are important to note, however trivial it seems to you. It is also helpful to know what blood relatives have died from. You may need to ask around, as families do not discuss these things as often as they did in the past.

Vaccination/Immunization History
It is important to include all these from birth onwards. Your Primary Care Physician should have records if you do not remember. Please remember to include any later vaccinations/ immunisations you may have had for travel, work, or from being in the armed forces including Covid 19 vaccination and booster. Note carefully any reactions to these, however slight.

Please see below and check all that apply

Whatcha' Been Doin'?
Current Medications and Supplements

MEDICATIONS
Please list any medications that you are now taking. Include non-prescription/over the counter medications. Please list the name of the drug, dose (include strength & number of pills per day), and how long have you been taking this?

SUPPLEMENTS
Please list any supplements, oral and intravenous vitamin drips that you are now taking. Include all vitamins and supplements. Example: DHEA, MSM, glucosamine chondroitin, selenium, manganese, etc. Please list the name of the supplement, dose (include strength & number of pills per day), and how long have you been taking this?

We at BiomeTech believe it is every person’s Divine right to live in Prosperity- Emotionally, Financially and Health-fully. In this way, we can work in partnership to improve your health. We look forward to being of service.  Here’s to your Health!

By signing and initialing below: You, the client, understand that when beginning this program and making changes in your nutritional and/or dietary habits, you may experience a period of detoxification.  If symptoms arise and you need assistance with your spray program or if you have questions, please call our office for assistance.

Possible Detoxification Symptoms Could Be:
Irritability, restlessness, fatigue, listlessness, bad dreams, bloating, nausea and flu like symptoms.

You may also experience a release of repressed emotions such as anger and sadness.

These are normal Detox Symptoms and they will pass as you continue your program.

Please also note that this information and any accompanying printed material is not intended to replace the attention or advice of physicians or other healthcare professionals. Anyone who wishes to embark on any dietary, drug, exercise, or other lifestyle change intended to prevent or treat a specific disease or condition should first consult with a qualified healthcare professional.

DISCLAIMER *The statements made regarding these products have not been evaluated by the Food and Drug Administration. The efficacy of these products has not been confirmed by FDA-approved research. These products are not intended to diagnose, treat, cure or prevent any disease. All information presented here is not meant as a substitute for or alternative to information from healthcare practitioners. Please consult your healthcare professional about potential interactions or other possible complications before using any product. The Federal Food, Drug, and Cosmetic Act requires this notice.*