Full Name:

Date of Birth:

Contact Number (Home or Mobile):

Email Address:

Full Address (including postcode):

Country of Residence:

Referred By:

Appointment Date:

Below are a series of questions about your current health and wellbeing. 

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 prescribed, over the counter, herbal supplements etc.) 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?

What are your goals from BodyTalk?

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

Do you suffer experience any of the following digestive health issues?

 

  • Loose stool

  • Diarrhea

  • Constipation

  • Poor digestion

  • Parasites

  • Acid reflux

  • Hiatal Hernia

  • Nausea / vomiting

  • Gas or belching

  • Stomach intestinal pain

  • Heartburn

  • Excessive appetite

  • Poor appetite

  • Irritable bowels

  • Hemorrohoids

 

If yes, please specify:

Do you experience any of the following cardiac health issues?

 

  • Hypertension

  • Hypotension

  • Chest pain

  • Hypotension

  • Chest pain

  • Dizziness

  • Easily bruised

  • Edema

  • Cold hands / feet

  • Restlessness

  • Heart palpitation

  • Slow heart rate

  • Poor circulation

  • Blood clots

  • Sweaty hands / feet

  • Anemia

  • Heart disease

  • Phlebitis

  • Poor blood clotting

  • Heart attack? If yes, how many times?

 

If yes, please specify:

Do you experience any of the following health issues?

 

  • Dyslexia

  • Epilepsy

  • Developmental or growth problems

  • Learning disorder

  • Head injury

  • Nervous disorder

  • Multiple Sclerosis

  • Numbness (specify where)

  • Muscular dystrophy

  • Tingling (specify where)

 

If yes, please specify:

Do you experience any of the following health issues?

 

  • TMJ pain

  • Facial pain

  • Loss of Balance

  • Poor coordination

  • Leg Weakness

  • Arm Weakness

  • Trunk Weakness

  • Difficulty walking

  • Joint swelling

  • Rheumatoid Arthritis

  • Artificial joints

  • Broken bones, fractures  

  • Pins, etc?

 

If yes, please specify:

Do you experience any of the following?

 

  • Infectious disease (please specify)

  • Specific skin condition (please specify)

  • Hepatitis? (type)

  • Cancer, Where?

  • Chemical/ drug/ alcohol dependency (please specify)

  • Poor sense of taste

  • Headaches

  • Migraines

  • Allergies? 

  • Eye pain

  • Dry eyes

  • Dizziness

  • Watery eyes

  • Herpes

  • Soft or brittle nails

  • Intolerance to temperature / weather changes

  • Dental problems

  • Poor hearing

  • Shingles

  • Chills

  • Difficulty swallowing

  • Candida

  • Nose bleeds

  • Diabetes

  • Swollen glands

  • Weight gain

 

If yes, please specify:

Do you experience any of the following respiratory health issues?

 

  • Wet cough

  • Dry cough

  • Chest tightness

  • Shortness of breath

  • Congestion

  • Wheezing

  • Poor sense of smell

  • Sinus problems

  • Nasal problems

  • Allergies

  • Hayfever

  • Pneumonia

  • Asthma

  • Emphysema

  • Bronchitis

  • Do you smoke?

 

If yes, please specify:

Do you experience any of the following endocrine health issues?

 

  • Breast pain/tenderness

  • Breast lumps

  • Breast cancer

  • Nipple discharge

  • Menopause

  • Menopausal symptoms

  • Are your cycles regular? (Please state length of cycle)

  • Painful menses with heavy or excessive flow

  • Painful intercourse

  • Ovarian cysts

  • Endometriosis

  • PMS

  • Infertility

  • Prostate pain

  • Impotence

  • Infertility

  • Prostate cancer

  • Problems urinating

  • Genital pains

     

If yes, please specify:

Do you experience any of the following health issues?

 

  • Insomnia

  • Fatigue

  • Weight loss

  • Depression

  • Difficulty with speech

  • Tuberculosis

  • Sleep too much (how long?)

  • No thirst

  • Thyroid problems
     

 

If yes, please specify:

Do you experience any pain, stiffness or limited movement in the following areas?

 

  • Shoulder

  • Legs

  • Arm

  • Knee

  • Elbow

  • Foot

  • Hands

  • Neck

  • Hip

  • Upper back

  • Mid back

  • Low back

 

If yes, please specify:

Do you experience any of the following urinary/ bladder health issues?

 

  • Painful urination

  • Difficulty with urination

  • Incontinence

  • Kidney stones

  • Kidney infections

 

If yes, please specify:

Do you experience any of the following:

 

  • Difficulty making plans or decisions

  • Easily angered

  • Obsessive tendencies in relationships

  • Difficulty making plans or decisions

  • Anxiety

 

If yes, please specify:

Delcaration


By Acknowledging the declaration below you are agreeing to the specified terms.

I understand that the BodyTalk session provided by this Certified BodyTalk Practitioner is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe, and objective. It utilizes the body’s own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the Practitioner prescribe medications.

 

 

Full Name:

Date Submitting:

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Gympie| Queensland| Australia

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