Health History Form Please complete only what you are comfortable with. More details can be given during the consultation if preferred. Name Phone Date of Birth Email Marital Status Single Married Widowed Children 1 2 3 4 5 Describe the problems for which you seek therapy. Please include approx dates when each problem started Severity of Impairment Mild Moderate Severe What daily activities are you finding difficult due to the complaint Past Medical History (injuries, accidents, surgeries, vaccinations, antibiotics exposure, medical tests etc) and include approximate dates List any medications, natural remedies or supplements you are taking What are your goals from BodyTalk, what would you like to change List any key life events that have had a significant impact on you (Bereavement, birth of a child, redundancy, accident, relationship breakdown etc) Please write the number that best describes the frequency or severity of the conditions below. Leave blank if there is never a problem Constipation Acid Reflux Diahorrea Excessive Appetite Poor Appetite High Cholesterol Irritable Bowels Nausea/Vomiting Stomach/Intestinal Pain Other RESPIRATORY Asthma Bronchitis Emphysema Congestion Sinus Problems Wheezing Chest Tightness Shortness of Breath Poor Sense of Smell Other CARDIOLOGY Anaemia Angina Blood Clots Dizziness Cold Hands/Feet Sweaty Hands / Feet Heart Palpitations Hypertension Hypotension Oedema Other URINARY Cystitis Difficulty With Urination Incontinence Kidney Infections Kidney Stones Other NERVOUS SYSTEM Learning Disorder Epilepsy Head Injury Nervous Disorder Other MUSCULOSKELETAL Limb Pain / Weakness Joint Pain / Weakness Back Pain Neck Pain Shoulder Pain Broken Bones Difficulty Walking Co-ordination / balance Osteoarthritis Other Facial Pain ALLERGIES / INTOLERANCES OTHER Fibromyalgia Fatigue Migraines / Headaches Obsessive Tendencies Poor Concentration Poor Memory Dental Problems Skin Conditions Previous Infections Bacterial or Viral Infections Details Hearing WEIGHT AND METABOLISM. Are you comfortable with your current weight Yes No Diabetes Thyroid Problems High Cholesterol Other SLEEP How Many Hours a Night do You Sleep Is Your Sleep Restful Yes No ARE YOU ABLE TO EXERCISE - If so, for how long ? Do You consume alcohol? No Occasionally Daily Excessively Do you smoke or vape? No Yes Do you have a chemical dependency? No Yes Do you seek comfort from food? No Yes If applicable, can you identify what emotional triggers may lead you to over eat, drink, smoke etc? Do you have any fears or phobias? STRESS 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 WOMEN ONLY Infertility PMS Menstrual Cycle Painful Intercourse Menopause Symptoms Breast Pain / Lumps Pregnancy Labour MEN ONLY Infertility Genital Pain Prostate Problems Other I understand that the holistic treatments provided by certified practitioners are intended to enhance relaxation, increase communication within the areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. The holistic treatments are non invasive, safe and utilise the body's own innate intelligence to re-establish communication within itself .I understand the treatments provided by Anne Archer - Holistic Health are not a substitute for medical treatments or medications. I am aware that the practitioner does not diagnose illness or disease nor does the practitioner prescribe medications. Send
