BodyTalk Intake Form
Health & Well Being History-Inner Architect
Krista Hurton CBP/BAT/Agent of STHU CLI Instructor
Email address *
First and Last Name *
Your answer
Phone Number *
Your answer
DOB *
MM
/
DD
/
YYYY
Please answer all the following questions honestly and to the best of your ability.
Describe the issues for which you are seeking help. *
Your answer
Past medical History ( Any Surgeries you have had) *
Your answer
Any traumas/accidents physical and/or emotional *
Your answer
Do you have any scars? Please describe where these are on your body. *
Your answer
What daily activities are you finding difficult or are limited by? *
Your answer
Have you been formally diagnosed? if so with what? *
Your answer
Please check all feelings that you are/have been experiencing as of late *
Required
Please choose level of stress for each scenario *
Minimal
Moderate
Severe
None
Family Stress
*
Minimal
Moderate
Severe
None
Relationship Stress
*
Minimal
Moderate
Severe
None
Work Stress
*
Minimal
Moderate
Severe
None
Financial Stress
*
Minimal
Moderate
Severe
None
Health Stress
How is your sleep? Please check all that apply. *
Required
Do you have any allergies? please list them below. *
Your answer
On a scale of 1-5, 5 being the most extreme level of pain please indicate the level of pain you are in most of the time *
Least
Most
What is your favorite color? *
Your answer
What is your least favorite color? *
Your answer
What is your favorite season? *
Your answer
What is your least favorite season? *
Your answer
Do you find that you feel cold most of the time or hot? or neither? *
Please tell me anything else you wish me to know
Your answer
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