Home Address: ______________________________________________________________________
Phone #’s:Cell(____)_____________ Home (____)_____________ Referred by:__________________
Marital Status: Married Single Divorced Widow
Spouse/Partner’s Name: ____________________
Children (Name/Age): ________________________________________
Work Status: Occupation: ______________________________
ISSUES FOR TREATMENT Please describe the problem for which you seek help. Please include the dates when each problem occurred and any other healthcare professionals that you are also seeing for this issue.
At Crystal Springs Energy Medicine we offer innovative and powerful energy medicine methods to create lasting clarity in your mind and body. Our philosophy is to gently, yet deeply, facilitate the awakening of each individual’s own healing ability for long-lasting and transformative change.
A BodyTalk session is safe and non-invasive. The intent of the session is to enhance your mind body communication and accelerate healing, but it is not a substitute for medical treatment. A BodyTalk Practitioner does not diagnose illness or prescribe medications.
Sessions times will vary per need; typical sessions are between 30 and 45 minutes. If you need to change your appointment please provide advanced notice. Appointments canceled with less than 24 hr notice will be charged $30. Returned checks will also incur a $30 fee.
With the understanding of the statements above, I consent to treatment.
Swallowing Difficulty Gas/Bloating After Meals REPRODUCTIVE
Heartburn Erectile Difficulties
Weight Problems Sexual Dysfunction
Gall Bladder Problems Menstrual Irregularity
Liver Problems Menstrual Cramping
How often do you have a bowel movement? ________ Are your movements consistent? Yes No
Please note any allergies: ______________________________________________________________
Have any of your family members every suffered from any of the following conditions?
Diabetes Neurological Disorders _________________ Cancer __________________
Stroke Depression/Mental Illness _______________ ________________________
PAST TRAUMA HISTORY Past stresses from physical trauma can lead to our current health problems. Please LIST Accidents (cars, etc.), Injuries (sports, work, etc,), and Surgeries that you have experienced.
CURRENT PAIN OR DISCOMFORT
Please SHADE areas of pain or discomfort on the body diagrams and RATE level of discomfort.
______________________ ______________________ ______________________
LIFESTYLE CHECK any of the following feelings you have notably experienced in the last few months.
Joy Rejected Cheerful Fear Anger