Lifetime Health History Form

Cuantico Coaching - Health Based Affirmations Generator
Lifetime Health History Form

Please select all the conditions you have ever had throughout your life. Also, if you have children 13 or under please check their conditions to add them to your affirmations. Once completed, a set of affirmations will be created at the end of the form for you to say out loud every day. Paste them into a document and follow the instructions. We do not collect any personal information that could identify you or store your answers. This is 100% confidential and is communicated only to you. These affirmations are not intended to cure any specific health conditions. It is important to understand that these affirmations spoken every day can significantly improve your healthcare providers ability to treat your condition by creating an internal emotional environment that is not producing stress hormone (cortisol) in excess.
Health Conditions / Problem Areas

Abdominal Cramps:Abscess:Accidents:Aches:Acne:Addictions:Addison's Dis-ease:Adenoids:Adrenal Problems:Aging Problems:AIDS / HIV:Alcoholism:Allergies:Alzheimer's Dis-ease:Amenorrhea:Amnesia:Amyotrophic Lateral Sclerosis:Anemia:Ankle(s):Anorectal Bleeding:Anorexia:Anus:Anus - Abscess:Anus - Bleeding:Anus - Fistula:Anus - Itching:Anus - Pain:Anxiety:Apathy:Appendicitis:Appetite - Excessive:Appetite - Loss of:Arm(s):Arteries:Arteriosclerosis:Arthritic Fingers:Arthritis:Asphyxiating Attacks:Asthma:Asthma - Babies and Children:Back:Back Problems - Lower BackBack Problems - Middle Back:Back Problems - Upper Back:Bad Breath:Balance, Loss of:Baldness:Bedwetting (Enuresis):Belching:Bell's palsy:Birth:Birth Defects:Bites:Bites - Animal:Bites - Bug:Blackheads:Bladder Problems (Cystitis):Bleeding:Bleeding Gums:Blisters:Blood:Blood Pressure - High:Blood Pressure - Low:Blood Problems:Blood Problems - Clotting:Body Odor:Boils (Furuncle):Bone(s):Bone Marrow:Bone Problems:Bone Deformity:Bowels:Bowel Problems:Brain:Brain - Tumor:Breast(s):Breast Problems:Breath:Breathing Problems:Bright's Dis-ease:Bronchitis:Bruises (Ecchymoses):Bulimia:Bunions:Burns:Bursitis:Buttocks:Callouses:Cancer:Candida (Candidiasis):Canker Sores:Carbuncle:Carpal-Tunnel Syndrome:Car Sickness:Cataracts:Cellulite:Cerebral Palsy:Cerebrovascular Accident (See Stroke):Childhood Dis-eases:Chills:Cholelithiasis:Cholesterol (Atherosclerosis):Chronic Dis-eases:Circulation:Cold Sores (Fever Blisters):Colds (Upper Respiratory Illness):Colic:Colon:Colitis:Coma:Comedones:Conjunctivitis:Constipation:Corns:Coronary Thrombosis (see Heart Attack):Coughs:Cramps:Croup:Crying:Cushing's Dis-ease:Cuts:Cyst(s):Cystic Fibrosis:Cystitis:Deafness:Death:Dementia:Depression:Diabetes (Hyperglycemia Mellitus):Diarrhea:Dizziness (Vertigo):Dry Eye:Dysentery:Dysentery - Amoebic:Dysentery - Bacillary:Dysmenorrhea:Ear(s):Earache (Otitis: External/Ear Canal, Media/Inner Ear):Ecchymoses:Eczema:Edema:Elbow:Emphysema:Endometriosis:Enuresis:Epilepsy:Epstein-Barr Virus:Extropia:Eye(s):Eye Problems:Eye - Astigmatism:Eye - Cataracts:Eye - ChildrenEye - Crossed (Keratitus):Eye - Farsighted:Eye - GlaucomaEye - Nearsighted:Eye - Wall Eyed (Extropia):Face:Fainting (Vasovagal Attack):Fat (Overweight):Fat - Arms:Fat - Belly:Fat - Hips:Fat - Thighs:Fatigue:Feet:Female Problems:Fever:Fever Blisters:Fibroid Tumors & Cysts:Fingers:Fingers - ThumbFingers - Index Finger:Fingers - Middle Finger:Fingers - Ring Finger:Fingers - Little Finger:Fistula:Flatulence (Gas Pains):Flu:Food Poisoning:Foot Problems:Frigidity:Fungus:Furuncle (Boils):Gallstones (Cholelithiasis):Gangrene:Gas Pains (Flatulence):GastritisGenitals:Genital Problems:Gland(s):Glandular Fever:Glandular Problems:Globus Hystericus:Goiter:Gonorrhea:Gout:Gray Hair:Growths:Gum Problems:Halitosis:Hands:Hay Fever:Headaches:Heart:Heart Attack:Heart Problems:Heartburn:Hematochezia:Hemorrhoids:Hepatitis:Hernia:Herpes (Genital):Herpes Simplex (Cold Sores):Hip(s):Hip Problems:Hirsutism:Hives (Urticaria):Hodgkin's Dis-ease:Holding Fluids:Huntington's Dis-ease:Hyperactivity:Hyperglycemia:Hyperopia:Hypertension:Hyperthyroidism:Hyperventilation:Hypoglycemia:Hypothyroidism:Ileitis (Crohn's Dis-ease, Regional Enteritis):Impotence:Incontinence:Incurable:Indigestion:Infection:Inflammation:Influenza:Ingrown Toenail:Injuries:Insanity (psychiatric illness):Insomnia:Intestines:Itching (Pruritus):"Itis":Jaundice:Jaw Problems (Temporomandibular Joint, TMJ Syndrome):Joints:Keratitus:Kidney Problems:Kidney Stones:Knee:Knee Problems:Laryngitis:Left Side of Body:Leg(s):Leg Problems:Leprosy:Leukemia:Leukorrhea:Liver:Liver Problems:Lockjaw:Lou Gehrig's Dis-ease:Lump in Throat (Globus Hystericus):Lung:Lung Problems:Lupus (Erythematosus):Lymph Problems:Malaria:Mastis:Mastoiditis:Mellitus:Menopause Problems:Menstrual Problems:Migraine Headaches:Miscarriage:Mono, Mononucleosis (Pfeiffer's Dis-ease, Glandular Fever):Motion Sickness:Mouth:Mouth Problems:Mucus Colon:Multiple Sclerosis:Muscles:Muscular Dystrophy:Myalgic Encephalomyelitis:Myocardial Infarction:Myopia:Nail(s):Nail Biting:Narcolepsy:Nausea:Neck (Cervical Spine):Neck Problems:Nephritis:Nerves:Nervous Breakdown:Nervousness:Neuralgia:Nodules:Nose:Nose Bleeds:Nose - Runny:Nose - Stuffy:Numbness (Paresthesia):Osteomyelitis:Osteoporosis:Ovaries:Overweight:Paget's Dis-ease:Pain:Palsy:Pancreas:Pancreatitis:ParalysisParasites:ParesthesiaParkinson's Dis-ease:Peptic Ulcer:Periodontitis:Petit Mal:Pfeiffer's Dis-ease:Phlebitis:Piles:Pimples:Pink Eye:Pituitary Gland:Plantar Wart:Pneumonia:Poison Ivy / Poison Oak:Polio:Post-Nasal Drip:Premenstrual Syndrome (PMS):Prostate:Prostate Problems:Pruritus:Pruritus Ani:Psoriasis:Psychiatric Illness:Pubic Bone:Pyelonephritis:Pyorrhea (Periodontitis):Quinsy (Peritonsillar Abscess):Rabies:Rash:Rectum:Respiratory Ailments:Rheumatism:Rheumatoid Arthritis:Rickets:Right Side of Body:Ringworm:Root Canal:Round Shoulders:Sagging Lines:Scabies:Sciatica:Scleroderma:Scoliosis:Scratches:Seasickness:Seizures:Senility:Shin(s):Shingles (Varicella):Shoulders:Sickle Cell Anemia:Sinus Problems (Sinusitis):Skeleton:Skin:Skin Problems:Slipped Disc:Snoring:Solar Plexus:Sores:Sore Throat:Spasms:Spastic Colitis:Spinal Curvature (Scoliosis Kyphosis):Spinal Meningitis:Spine:Spleen:Sprains:Sterility:Stiff Neck:Stiffness:Stomach:Stomach Problems:Stroke (Cerebrovascular Accident/CVA):Stuttering:Sty:Suicide:Swelling:Syphilis:Tapeworm:Teeth - Problems:Temporomandibular Joint:Testicles:Tetanus:Throat:Throat Problems:Thrush:Thymus:Thyroid:Tics, Twitches:Tinnitus:Toes:Tongue:Tonsilitis:Tuberculosis:Tumors:Ulcers:Urethritis:Urinary Infections (Cystitis, Pyelonephritis):Urticaria:Uterus:Vaginitis:Varicella:Varicose Veins:Vasovagal Attack:Venereal Dis-ease:Vertigo:Viral Infections:Vitiligo:Vomiting:Vulva:Warts:Weakness:Whiteheads:Wisdom Tooth, Impacted:Wounds:Wrist:Yeast Infections:
Below are the specific affirmations based on your selections. Instructions: Read these out loud every morning when you wake up and every night before you go to sleep. Within 60-90 days if you continue to do this consistently, you will see improvement in all areas of your health, mind, and emotions. To learn more about Cuantico Coaching, visit our website at: www.cuanticocoaching.com
To learn more about the amazing woman behind the groundbreaking work that is the foundation of this tool, we encourage you to visit https://www.louisehay.com or purchase her book. Simply click on the image below to access the book on amazon.com.
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Cuantico Coaching - Health Based Affirmations Generator

Lifetime Health History Form