First Name
*
Last Name
*
Date of birth
Email
*
Phone
*
Occupation
City
*
Health conditions/concerns
What symptoms are you experiencing?
Fatigue / Low energy
Brain fog / Memory issues / Poor focus
Low immunity (Frequent colds, Slow recovery)
Respiratory symptoms (Shortness of breath, Chronic cough)
Stress / Anxiety / Low mood / Mood swings / Irritability
Pain (Back pain, Joint pain, Muscle aches)
Sleep problems (Insomnia, Poor sleep quality)
Headaches / Migraines
Digestive issues (Bloating, IBS, Constipation, Reflux)
Weight gain / Difficulty losing weight
Skin issues (Eczema, Acne, Rashes)
Hormonal imbalances (PMS, Perimenopause, Thyroid)
Allergies / Hayfever / Food sensitivities
High blood pressure / Cardiovascular symptoms
When did your symptoms or conditions begin?
What therapies have you tried
Any medical conditions or injuries we should be aware of?
If your health improved significantly, what activities or experiences would you love to enjoy again?
Have more energy and feel like myself again
Reduce or eliminate daily pain
Sleep better and wake up refreshed
Get back to work or hobbies I enjoy
Rebuild my immune system and resilience
Be more present for family and loved ones
Enjoy travel or social activities again
Restore appetite, digestion, or weight balance
Feel confident in my body and health choices
Regain a sense of calm, confidence, and hope
How long have you had your Bioptron device?
What Bioptron model(s) do you have?
Feedback on this form or anything else you would like us to know
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