Your Name (required)
Your Email (required)
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Home Phone
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Referred by
Date of Birth
Please answer the following questions honestly and to the best of your ability
Describe the problems(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 are 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 heal care professional you are seeing for this/these problem(s)
Please list any medical tests you have had within the past year
Please select the number that best describes the frequency you experience the below conditions. Leave unselected if there is never a problem.
Digestion
Loose stool or Diarrhea 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
Irritable bowels 1 2 3 4
Hemorrhoids 1 2 3 4
Blood in stool 1 2 3 4
Black or dark stool 1 2 3 4
Light colored stool 1 2 3 4
Difficulty digesting oily food 1 2 3 4
High cholesterol Yes No
Gall stones Yes No
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
Nasal problems 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
Catches colds easily 1 2 3 4
Other
Pneumonia Yes No
Asthma Yes No
Emphysema Yes No
Bronchitis Yes No
Do you smoke? Yes No How many packs per day?
Cardiovascular
Hypertension 1 2 3 4
Hypotension 1 2 3 4
Chest pain 1 2 3 4
Dizziness 1 2 3 4
Easily bruised 1 2 3 4
Edema 1 2 3 4
Cold hands/feet 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
Blood clots 1 2 3 4
Sweaty hands/feet 1 2 3 4
Anemia 1 2 3 4
Poor blood clotting 1 2 3 4
Heart disease Yes No
Phlebitis Yes No
Heart attack Yes No How many times?
Stroke Yes No How many times?
Other:
Urinary
Painful urniation 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 Yes No
Kidney stones Yes No
Kidney infections Yes No
Low back pain Yes No
Knee pain Yes No
Nervous System
Dyslexia Yes No
Learning disorder Yes No
Multiple Sclerosis Yes No
Muscular dystrophy Yes No
Epilepsy Yes No
Head injury Yes No
Numbness Yes No Where?
Tingling Yes No Where?
Development or growth problems Yes No
Nervous disorder Yes No Type?
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
Osteoarthritis Yes No
Rheumatoid arthritis Yes No
Artificial joints Yes No
Broken bones, fractures Yes No Where?
Pins, etc Yes No Where?
Please select Yes or No to indicate whether you've had pain in that area or not and please select which side it was on, Left or Right.
Shoulder Yes No Left Right
Arm Yes No Left Right
Elbow Yes No Left Right
Hands Yes No Left Right
Hip Yes No Left Right
Legs Yes No Left Right
Knee Yes No Left Right
Foot Yes No Left Right
Neck Yes No Left Right
Upper back Yes No Left Right
Mid back Yes No Left Right
Low back Yes No Left Right
Limited Movement Yes No
Insomnia 1 2 3 4
Depression 1 2 3 4
Sleep too much 1 2 3 4 How long?
Shaky 1 2 3 4
Poor memory 1 2 3 4
Difficulty paying attention 1 2 3 4
Anxiety 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
Intolerance to temperature/weather changes 1 2 3 4
Fever 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
Difficulty with speech 1 2 3 4
No thirst 1 2 3 4
Excessive thirst 1 2 3 4
Dry mouth 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
Dry eyes 1 2 3 4
Watery eyes 1 2 3 4
Other eye problems? 1 2 3 4
Dental problems Yes No
Poor hearing Yes No
Difficulty swallowing Yes No
Diabetes 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
Cancer Yes No Where?
Hepatitis Yes No Type:
Infectious disease Yes No What disease(s)?
Herpes Yes No
Candida Yes No
Shingles Yes No
Chemical dependency Yes No Explain please:
Skin condition Yes No Explain please:
Pain associated with genitals 1 2 3 4
Impotence 1 2 3 4
Problems urinating 1 2 3 4
Infertility 1 2 3 4
Prostrate cancer 1 2 3 4
Breast pain or tenderness 1 2 3 4
Breast lumps Yes No
Nipple discharge Yes No
Menopause Yes No
Menopausal symptoms Yes No
Are your cycles regular? Yes No Length?
Painful intercourse Yes No
Ovarian cysts Yes No
Endometriosis Yes No
PMS Yes No
Infertitliy Yes No
Please check any of the following feelings you have experienced in the last few months
Abused Criticized Overworked Paralyzed Depressed Rejected Despair Helpless Hopeless Paranoid Overwhelmed Muddled Guilty Easily irritated Anxious Sad Grieving Unable to grieve Apprehensive Agitated Uneasy Distress Fearful Impatient Intimidated Restless Panic Intolerant Uncertainty Aggravated Annoyed Angry Outraged Nervous Worried
Please select 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 Explain please:
How much time do you have for yourself to relax and what do you do to relax, i.e.. hobbies, meditation, etc.?
Do you exercise? Yes No If so, what kind and how often?
How many hours a night do you sleep? Is your sleep restful? Yes No If not, please explain:
Please list areas of pain and select the circle that best describes the level of discomfort on a scale of 1 - 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
1 2 3 4 5 6 7 8 9 10
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