Health And Well Being History Form

Name: Address: Home Phone: Cellular Phone: Date: Email: City, State, Zip: Other Phone: Referred by: Date of Birth:

PART 1.
* Please answer the following questions honestly and to the best of your ability. 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 nding difcult 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:

* Please

PART 2.

mark the circle that best describes the frequency you experience the below conditions. Leave blank if there is never a problem. 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
yes yes yes yes

1 2 3 4

Rarely (once a month or less) Occasionally (less than once a week) Frequently (more than once a week) Constantly 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
yes yes yes yes yes yes yes

DIGESTION

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
no no no no

Loose stool or Diarrhea Constipation Poor digestion Parasites Acid reux Hiatal Hernia Nausea / vomiting Wet cough Dry cough Chest tightness Shortness of breath Congestion Wheezing Hypertension Hypotension Chest pain Dizziness Easily bruised Edema Cold hands / feet Painful urination Incontinence Difculty with urination Ringing in ears Dyslexia Learning disorder Multiple Sclerosis Muscular dystrophy TMJ pain Facial pain Loss of Balance Poor coordination Leg Weakness

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
no no no no no no no

Gas or belching Stomach or intestinal pain Heartburn Excessive appetite Poor appetite Irritable bowels Hemorrohoids Nasal problems Poor sense of smell Sinus problems Allergies Hay fever Catches colds easily Restlessness Heart palpitation Slow heart rate Poor circulation Blood clots Sweaty hands / feet Anemia Ear aches Hearing impairment Kidney stones Kidney infections Epilepsy Head injury Numbness, Where? _________________________ Tingling, Where? _________________________ Arm Weakness Trunk Weakness Difculty walking Joint swelling Osteoarthritis

1 1 1 1

2 2 2 2
yes yes

3 3 3 3

4 4 4 4
no no

Blood in stool Black or dark stool Light colored stool Difculty digesting oily food High cholesterol Gall stones

RESPIRATORY

1 1 1 1 1 1

2
yes yes yes yes yes yes yes

4
no no no no no no no

Other: _______________ Pneumonia Asthma Emphysema Bronchitis Do you smoke? Number per day: _____ Heart disease Phlebitis Poor blood clotting Heart attack How many times? ____ Stroke How many times? ____ Other: _______________

CARDIOVASCULAR

1 1 1 1 1 1 1

2
yes yes yes

4
no no no

URINARY

1 1 1 1

yes yes yes

no no no

Low back pain Knee problems Other: _______________

NERVOUS SYSTEM

yes yes

no no

Developmental or growth problems Nervous disorder? Type: _______________

MUSCLES / JOINTS

1 1 1 1 1

2 2 2 2 2

3 3 3 3 3

4 4 4 4 4

1 1 1 1

2 2 2 2
yes

3 3 3 3

4 4 4 4
no

yes yes yes yes

no no no no

Rheumatoid Arthritis Articial joints Broken bones, fractures? ______________________ ______________________ Pins, etc? ______________________ 2.

MUSCLES / JOINTS (cont)

Mark the circle of painful areas, and indicate on which side: (R) right and / or (L) left yes yes yes yes yes no no no no no Shoulder Arm Elbow Hands Hip Insomnia Depression Sleep too much, how long? __________________________ Shaky Poor memory Difculty paying attention Anxiety Easily angered Obsessive tendencies in work relationships Difculty making plans or decisions Dizziness Soft or brittle nails Intolerance to temperature / weather changes Fever Chills Nose bleeds Swollen glands Prostate problems Pain associated with genitals Breast pain or tenderness Breast lumps Nipple discharge Menopause

R R R R R

L L L L L

yes yes yes yes yes

no no no no no

Legs Knee Foot Neck Upper back

R R R R R

L L L L L

yes yes

no no

Mid R L back Low R L back Limited movement? Where? ___________ ___________________ ___________________

yes

no

OTHER

1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2
yes yes yes

3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3 3

4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4 4
no no no

1 1 1 1 1 1 1 1 1 1 1 1
yes yes yes yes yes

2 2 2 2 2 2 2 2 2 2 2 2

3 3 3 3 3 3 3 3 3 3 3 3
no no no no no

4 4 4 4 4 4 4 4 4 4 4 4

Fatigue Difculty with speech No thirst Excessive thirst Dry mouth Pain at night Headaches Migraines Eye pain Dry eyes Watery eyes Other eye problems? _________________________ Dental problems Poor hearing Difculty swallowing Diabetes Weight gain

yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes yes

no no no no no no no no no no no no no no no no no no no no no

Weight loss Tuberculosis Thyroid problems Fibromyalgia Poor sense of smell Poor sense of taste Cancer, Where? ___________________ Allergies? List: ___________________ ___________________ Hepatitis? type: ____ Infectious disease: ___________________ Herpes Candida Shingles Chemical dependency ___________________ ___________________ Skin condition: ____ __________________ Infertility Prostate cancer Ovarian cysts Endometriosis PMS Infertility

MEN ONLY

1 1 1

1 1
yes yes yes yes

2 2

3 3
no no no no

4 4

Impotence Problems urinating Menopausal symptoms: _________________________ Are your cycles regular? Length of cycle: __________ Painful menses with heavy or excessive ow Painful intercourse

WOMEN ONLY

* Please circle any of the following feelings you have experienced in the last few months.
WELL BEING Abused Criticized Overworked Paralyzed Depressed Rejected Despair Helpless Hopeless Paranoid Overwhelmed Muddled Persecuted 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 mark the circle that best describes the level of stress for the below listings.
My family stress is: My relationship stress is: My work stress is: My nancial stress is: My health stress is: Other stress is ________________: None None None None None None Minimal Minimal Minimal Minimal Minimal Minimal Moderate Moderate Moderate Moderate Moderate Moderate Severe Severe Severe Severe Severe Severe 3.

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: ________________ 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.

PART 3.
* Please list areas of pain and mark the circle that best describe the level of discomfort on a scale of 1 to 10. 1 1 1 1 2 2 2 2 3 3 3 3 4 4 4 4 5 5 5 5 6 6 6 6 7 7 7 7 8 8 8 8 9 10 9 10 9 10 9 10
example:

neck

1 1 1 1

2 2 2 2

3 3 3 3

4 4 4 4

5 5 5 5

6 6 6 6

7 7 7 7

8 8 8 8

9 10 9 10 9 10 9 10

PART 4.
* Please shade areas of pain or discomfort on the body diagrams and make comments on the side if necessary.
FRONT BACK COMMENTS:

Right

Left

Left

Right

Practitioners comments:

Client signature: Practitioner signature:

Date: Date:
copyright c 2005 by International BodyTalk Association

4.