Health History Intake & Consent Form

Health History Intake & Consent Form
Client's Information

FirstLast
Address

Street Address

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
ie. Sam412@gmail.com
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? If so, when?
What are your goals for 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:
Please check any of the following feelings you have experienced in the last few months

AbusedCriticizedOverworkedParalyzedDepressedRejectedDespairHelplessHopelessParanoidOverwhelmedMuddledPersecutedGuiltyEasily irritatedAnxiousSadGrievingUnable to grieveApprehensiveAgitatedUneasyDistressFearfulImpatientIntimidatedRestlessPanicIntolerantUncertaintyAggravatedAnnoyedAngryOutragedNervousWorried
Please select the option that best describes the level of stress you're experiencing in the following areas of your life:
My family stress is:

NoneMinimalModerateSevere
My relationship stress is:

NoneMinimalModerateSevere
My work stress is:

NoneMinimalModerateSevere
My financial stress is:

NoneMinimalModerateSevere
My health stress is:

NoneMinimalModerateSevere
My other stress is:
Describe any other area of your life that's presenting stress and indicate its stress level below.
NoneMinimalModerateSevere
How much time do you have for yourself to relax, and what do you do to relax? (e.g. hobbies, meditation, etc.)
Do you exercise? If so, what kind and how often?
How many hours a night do you sleep? Is your sleep restful? If not, please explain:
Please shade areas of pain or discomfort on the body diagrams and make corresponding comments in the space below:
Pain chart comments:
How did you hear about me ?

Word of MouthWebsite SearchSocial MediaBodyTalk WebsiteOther
Consent
I First Name Last Name (Insert First Name and Last Name), 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 be creating pain, discomfort and disease. BodyTalk is non-invasive, safe and objective. It utilizes the body's own innate intelligence to re-establish 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 BodyTalk Practitioner prescribe medications. I understand that participation in a BodyTalk session is voluntary and that I may choose to end our participation at any time.

I agree to pay a fee of $ ______ per session and agree that payment is due at the time of the service. I understand that a 24-hour cancellation is required if I am unable to attend the session.

By signing and submitting this form, I hereby authorize the BodyTalk Practitioner to provide me with a BodyTalk session(s).
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