Intake Form (Human)

Phone number
Date of birth (dd/mm/yyyy)
Describe the issue(s) for which you seek help:
What are 3-5 issues that are holding you back in your life? Please provide a rating on a scale of 1 to 10 of how much this currently limits your life, 10 representing extreme limitation. For example, "I'd like to heal the pain in my leg - 7"
How would you design your ideal life? List 3-5 positive changes that you would like to see in your life. For example, "I'd like to travel to Australia." or "I want to have a better relationship with my son." Number these in order of importance to you.
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:
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 select the level that best describes your family stress:
Please select the level that best describes your relationship stress:
Please select the level that best describes your work stress:
Please select the level that best describes your financial stress:
Please select the level that best describes your health stress:
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? Please explain:
Please list areas of pain (eg. neck, right knee) and list the level of discomfort on a scale of 1 - 10 (10 is worst):
How did you find out about BodyTalk California?
Excerpt from a scientific evaluation of BodyTalk as published by Nova Science Publishers: "The blinded treatment group showed significant improvements compared to the control group for pain level, anxiety, and satisfaction with social role measures. Fatigue, overall physical and mental health showed significance in the pooled treatment group data ... this mind-body complimentary and alternative medicine system is effective in reducing pain level as well as emotional symptoms associated with long-term chronic pain." Click here to read the full study. 

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