Health And Well-Being History Form

Please answer the following questions honestly and to the best of your ability.

Name

E-mail

Is this booking for You, a Child, a Group or Business?

Address

City, State, Country

Cellular Phone

Home Phone

Date

Date of Birth

Describe the problem(s) for which you seek help. Please include dates when each problem occurred:

Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates:

List the medications (including over the counter) you are presently taking:

What daily activities are you ﬁnding difﬁcult or are limited because of your above complaints:

Have you ever had this problem before, and if so when?

Please list any other kind of healthcare professional you are seeing for this/these problem(s):

Please list any medical tests you have had within the past year:

What outcomes would you like to achieve with BodyTalk?

Please mark the circle that best describes the level of stress for the below listings.

My family stress is:

None Minimal Moderate Severe

My relationship stress is:

None Minimal Moderate Severe

My work stress is:

None Minimal Moderate Severe

My ﬁnancial stress is:

None Minimal Moderate Severe

My health stress is:

None Minimal Moderate Severe

Other stress is

None Minimal Moderate Severe

How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ?

Do you exercise? And if so, what kind and how often?

Describe your sleep

Please list areas of pain and mark the circle that best describe the level of discomfort on a scale of 1 to 10.

1. Slight awareness of discomfort.
2-3. Awareness of discomfort as an aggravation.
4-6. Pain is strong but you are still functional.
7-9. Pain is so strong you are unable to function normally.
10. You feel like you need to go to the emergency room.

Mark areas of pain or discomfort on the body diagram with a red dot and comment underneath if necessary.

What outcomes would you like to achieve with BodyTalk?

Client Signature:

Further Comments:

Acceptance

I agree payment is due at time of service as time has been especially reserved for me