Full Name

Date of birth

Address

Email *

City

Phone *

Postal code

Referred by:

Date form completed *

PART 1

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

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

List all medications vitamins, supplements that you are taking (including prescription, over the counter, herbal and homeopathic)

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):

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

Are you right-handed?

Yes, right-handed

No, left-handed

CHEMICAL STRESSORS

Have you taken any antibiotics in the past? If so, what age(s) were you?

Please indicate if you regularly consume any of the following: alcohol, recreational drugs, artificial sweeteners, refined sugar, caffeine, tap water, tobacco

PART 2

Please mark the circle that best describes the frequency you experience the below conditions. Leave blank if there is never a problem.

1 = Rarely (once a month or less)

2 = Occasionally (less than once a week)

3 = Frequently (more than once a week)

4 = Constantly

DIGESTION

Loose stool or diarrhoea

1

2

3

4

Constipation

1

2

3

4

Poor digestion

1

2

3

4

Parasites

1

2

3

4

Acid reflux

1

2

3

4

Hiatal Hernia

1

2

3

4

Nausea / vomiting

1

2

3

4

Gas or belching

1

2

3

4

Stomach or intestinal pain

1

2

3

4

Heartburn

1

2

3

4

Excessive appetite

1

2

3

4

Poor appetite

1

2

3

4

Blood in stool

1

2

3

4

Black or dark stool

1

2

3

4

Light coloured stool

1

2

3

4

Difficulty digesting oily food

1

2

3

4

High cholesterol

1

2

3

4

Gall stones

Yes

No

Irritable bowels

Yes

No

Any other issues

Describe your digestion, including average bowel production, time and day, number of times per day / week.

Please describe your diet (what you eat and when, including snacks and drinks)

RESPIRATORY

Wet cough

1

2

3

4

Dry cough

1

2

3

4

Chest tightness

1

2

3

4

Shortness of breath

1

2

3

4

Congestion

1

2

3

4

Wheezing

1

2

3

4

Poor sense of smell

1

2

3

4

Sinus problems

1

2

3

4

Allergies

1

2

3

4

Hay fever

1

2

3

4

Nasal problems

1

2

3

4

Catch colds easily

1

2

3

4

Asthma

Yes

No

Pneumonia

Yes

No

Emphysema

Yes

No

Bronchitis

Yes

No

Do you smoke?

Yes

No

How many per day?

Any other respiratory issues?

CARDIOVASCULAR

Hypertension

1

2

3

4

Hypotension

1

2

3

4

Chest pain

1

2

3

4

Easily bruised

1

2

3

4

Cold hands / feet

1

2

3

4

Dizziness

1

2

3

4

Edema

1

2

3

4

Restlessness

1

2

3

4

Heart palpitation

1

2

3

4

Slow heart rate

1

2

3

4

Poor circulation

1

2

3

4

Sweaty hands / feet

1

2

3

4

Blood clots

1

2

3

4

Poor blood clotting

1

2

3

4

Phlebitis

Yes

No

Heart disease

Yes

No

Heart attack

Yes

No

How many heart attacks?

Stroke

Yes

No

How many strokes?

URINARY

Painful urination

1

2

3

4

Incontinence

1

2

3

4

Difficulty with urination

1

2

3

4

Ringing in ears

1

2

3

4

Ear aches

1

2

3

4

Hearing impairment

1

2

3

4

Kidney stones

1

2

3

4

Kidney infections

1

2

3

4

Lower back pain

Yes

No

Knee problems

Yes

No

Other problems

NERVOUS SYSTEM

Dyslexia

Yes

No

Learning disorder

Yes

No

Multiple Sclerosis

Yes

No

Muscular dystrophy

Yes

No

Developmental or growth problems

Yes

No

Epilepsy

Yes

No

Nervous disorder?

Yes

No

Head injury

Yes

No

Type of nervous disorder

Tingling, where?

Numbness, where?

MUSCLES / JOINTS

TMJ pain

1

2

3

4

Facial pain

1

2

3

4

Loss of Balance

1

2

3

4

Poor coordination

1

2

3

4

Leg weakness

1

2

3

4

Arm weakness

1

2

3

4

Trunk weakness

1

2

3

4

Difficulty walking

1

2

3

4

Joint swelling

1

2

3

4

Haemorrhoids

1

2

3

4

Anaemia

1

2

3

4

Osteoarthritis

Yes

No

Broken bones, fractures?

Yes

No

Rheumatoid Arthritis

Yes

No

Pins, etc?

Yes

No

MUSCLE / JOINT PAIN

Do you have any joint or muscle pain in these areas? Please indicate on which side: right and / or left.

Shoulders

Left

Right

Arms

Left

Right

Wrists

Left

Right

Elbows

Left

Right

Legs

Left

Rght

Knees

Left

Right

Hips

Left

Right

Feet

Left

Right

Upper back

Left

Right

Mid back

Left

Right

Lower back

Left

Right

Limited movement? Where?

OTHER ISSUES

Insomnia

1

2

3

4

Depression

1

2

3

4

Shaky

1

2

3

4

Difficulty paying attention

1

2

3

4

Anxiety

1

2

3

4

Poor memory

1

2

3

4

Easily angered

1

2

3

4

Obsessive tendencies in work relationships

1

2

3

4

Difficulty making plans or decisions

1

2

3

4

Soft or brittle nails

1

2

3

4

Fever

1

2

3

4

Dizziness

1

2

3

4

Intolerance to temperature / weather changes

1

2

3

4

Pain at night

1

2

3

4

Headaches

1

2

3

4

Migraines

1

2

3

4

Eye pain

1

2

3

4

Chills

1

2

3

4

Nose bleeds

1

2

3

4

Swollen glands

1

2

3

4

Fatigue

1

2

3

4

No thirst

1

2

3

4

Excessive thirst

1

2

3

4

Dry mouth

1

2

3

4

Difficulty with speech

1

2

3

4

Dry eyes

1

2

3

4

Watery eyes

1

2

3

4

Other eye problems?

Dental problems

Yes

No

Poor hearing

Yes

No

Difficulty swallowing

Yes

No

Diabetes

Yes

No

Weight gain

Yes

No

Weight loss

Yes

No

Tuberculosis

Yes

No

Thyroid problems

Yes

No

Fibromyalgia

Yes

No

Poor sense of smell

Yes

No

Poor sense of taste

Yes

No

Candida

Yes

No

Herpes

Yes

No

Shingles

Yes

No

Any cancer? If so, where and when?

Allergies? Please list:

Hepatitis? Type:

Infectious disease:

Chemical dependency:

Skin condition:

WOMEN ONLY

Nipple discharges

Yes

No

Ovarian cysts

Yes

No

Menopause

Yes

No

Endometriosis

Yes

No

Breast lumps

Yes

No

Infertility

Yes

No

Breast pain or tenderness

1

2

3

4

Pain during intercourse

Usual cycle length / are they regular?

Painful menses with heavy / excessive flow

PMS symptoms / severity

Any menopausal symptoms

MEN ONLY

Pain associated with genitals

1

2

3

4

Problems urinating

1

2

3

4

Impotence

1

2

3

4

Prostate problems

1

2

3

4

Prostate cancer

Yes

No

WELLBEING

Have you experienced any of the following feelings in the last few months?

Check all that apply:

Abused

Criticised

Overworked

Paralysed

Depressed

Rejected

Despair

Helpless

Hopeless

Paranoid

Overwhelmed

Muddled

Persecuted

Guilty

Easily irritated

Anxious

Sad

Grieving

Unable to grieve

Annoyed

Angry

Apprehensive

Agitated

Uneasy

Distress

Fearful

Impatient

Intimidated

Restless

Panic

Intolerant

Uncertainty

Outraged

Nervous

Worried

Do you have any past experiences that still deeply affect you (trauma, grief, vaccine, illness etc.) You do not need to go into detail here. Just YES and age, if relevant.

What areas of life give you joy and energy?

Do you feel healthy? If not, please elaborate.

Do any family members have similar health issues?

Do you have any difficulties with family members, or have you in the past?

Do you have any other relationship difficulties?

STRESS

Please indicate which best describes the

level of stress for the following areas of your life.

Using this scale:

None / Minimal / Moderate / Severe

My family stress is:

My relationship stress is:

My work stress is:

My financial stress is:

My health stress is:

My other stress is:

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?

How many hours a night do you sleep?

Is your sleep restful? If not, please explain:

HISTORY OF EMOTIONAL STRESS

Rated 0 - 10 (0 = no stress, 10 = most severe)

Abuse

Childhood

Commuting

Divorce/separation (yours)

Financial

Family

Friends

Illness

Illness of loved ones

Job loss

Lifestyle change

Loss of loved ones

Moving house

School issues

Work issues

Your parents’ divorce

PART 3

Please list all the areas of your body where you have pain or discomfort. For example, stabbing pain left knee / rating 4.

Rate the discomfort from 1 - 10 according to this scale:

1 = Slight awareness of discomfort.

2 to 3 = Awareness of discomfort as an aggravation.

4 to 6 = Pain is strong but you are still functional.

7 to 9 = Pain is so strong you are unable to function normally.

10 = You feel like you need to go to the hospital.

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

Area of body / rating

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

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