BodyTalk Health and Well Being Form
BodyTalk Intake Form
Email address *
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First Name *
Last Name *
Telephone / Whatsapp *
Age/ Date of Birth *
Describe the problem(S) for which you seek BodyTalk. 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 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: *
STRESS LEVELS
Family Stress
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Relationship Stress
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Work Stress
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Financial Stress
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Health Stress
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How much time do you have for yourself to relax and what do you do to relax? *
Do you exercise? And if so what kind and how often? *
How many hours a night do you sleep? *
Is your sleep restful? If no, please explain: *
Date of Completion of this Form *
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Anything else worth mentioning? *
How did you hear about BodyTalk? *
Thank you for registering for your BodyTalk Session with Sufen Paphassarang. Your session is confidential and any information about your session will not be disclosed to anyone unless you give us written permission to do so. Unfortunately, no data transmission over the Internet can be guaranteed 100% secure. Accordingly, despite our best efforts to protect your personal information, Release cannot completely ensure or warrant the security of any information transmitted for our online products or services. You transmit all such information at your own risk. Once receiving your information, we will make every effort to ensure its security on our systems. BodyTalk session provided by Sufen Paphassarang, Release, Advanced Certified BodyTalk Practitioner, is intended to enhance relaxation and increase communication within areas of the body. You also understand that the BodyTalk System is not a substitute for medical treatment or medications. There is also no diagnosis of illness or disease nor prescription of medications. You understand that participation in any session is always voluntary and that you may choose to end your participation at any time. You understand that information exchanged during any session is educational in nature and is to be used at your own discretion.  You understand that by providing this informed consent you are assuming full responsibility for the session and hold harmless the IBA, BodyTalk Practitioner, health clinic, and facility/location where the session is provided. Payment is to be made after you have received your session. Please give 24 hours notice if you are unable to make your appointment. It is common to have people on the waiting list, so cancelling with enough notice allows others to receive much needed treatment. In the event of a late cancellation or non attendance, the full fee will apply. If you have any questions about these matters, please feel free to email Sufen Paphassarang at sufen@release.com.sg  By clicking below, you acknowledge that you have read and understood this document and agree to its terms and wish to proceed with a BodyTalk session with Sufen Paphassarang. *
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