BodyTalk Health and Well Being Form
BodyTalk Intake Form
Email address *
First Name *
Your answer
Last Name *
Your answer
Telephone / Whatsapp *
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Date of Birth *
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Describe the problem(S) for which you seek BodyTalk. Please include dates when each problem occurred: *
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Past medical history (previous injuries, accidents, surgeries etc) Please describe and include approximate dates
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List the medications (including over the counter) you are presently taking:
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What daily activities are you finding difficult or are limited because of your above complaints:
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Have you ever had this problem before, and if so when?
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What are your goals from BodyTalk?
Your answer
Please list any other kind of healthcare professional you are seeing for this/these problem(s):
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Please list any medical tests you have had within the past year:
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STRESS LEVELS
Family Stress
Relationship Stress
Work Stress
Financial Stress
Health Stress
How much time do you have for yourself to relax and what do you do to relax?
Your answer
Do you exercise? And if so what kind and how often?
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How many hours a night do you sleep?
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Is your sleep restful? If no, please explain:
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Anything else worth mentioning?
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Date of Completion of this Form *
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