Confidential patient information



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Crystal Springs Energy Medicine

Holistic Healthcare for the Whole Family
CONFIDENTIAL PATIENT INFORMATION
Name: ______________________________________ Date: ____/____/______

Email Address: ______________________________________ Birth date: ____/____/______

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.
1.______________________________________________________________________________

2.______________________________________________________________________________

3.______________________________________________________________________________
INFORMED CONSENT

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.

____________________________________________________ ______________



SIGNATURE DATE

HEALTH HISTORY
CHECK any of the following conditions you have HAD and CIRCLE anything you HAVE.
 Mental Disorders  Diabetes  Pneumonia  Infective Diseases___

 Epilepsy  Anemia  Tuberculosis  Fungal Infection____

 Tumors  Glaucoma  Hepatitis___  Herpes____

 Alcoholism  Heart Disease  Thyroid Disease  Arthritis

 Drug Addiction  Rheumatic Fever  Parasites  Autoimmune Disease

 Cancer  Scarlet Fever  Venereal Infection  _________________


NERVOUS SYSTEM CARDIOVASCULAR URINARY

 Depression  Chest Pain  Bladder Trouble

 Memory Loss/Confusion  Irregular Heartbeat  Painful Urination

 Dizziness  High Blood Pressure  Excessive Urination

 Fainting  Shortness of Breath  Incontinence

 Convulsions  Lung Problems/Congestion  Discolored Urination

 Numbness  Varicose Veins

 Weakness  Ankle Swelling MUSCULOSKELETAL

 Poor Balance/Coordination  Jaw Pain  Twitches/Tremor  Difficulty Chewing

 Cold/Tingling Extremities GASTROINTESTINALFace Pain

 Sleeping Difficulties  Poor/Excessive Appetite  Neck Pain

 Headaches  Excessive Thirst  Arm/Elbow Pain

 Frequent Nausea  Wrist/Hand Pain

EYES, EARS NOSE, THROAT  Vomiting  Mid Back Pain

 Vision Problems  Frequent Diarrhea  Lower Back Pain

 Flashing Lights  Frequent Constipation  Thigh/Knee Pain

 Black Spots  Hemorrhoids  Ankle/Foot Pain

 Blurriness  Black/Bloody Stools  Difficulty Walking

 Hearing Loss  Digestive Problems  Leg/Arm Fatigue

 Ringing in Ears  Abdominal Cramping

 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 __________________

 Heart Disease  Autoimmune Diseases _________________ _  ________________________

 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.


Approx Date

Description























CURRENT PAIN OR DISCOMFORT

Please SHADE areas of pain or discomfort on the body diagrams and RATE level of discomfort.


Ratings:


1

Slight awareness of discomfort

2-3

Awareness of discomfort as an aggravation

4-6

Pain is strong but you are still functional

7-9

Pain is so strong you are unable to function normally

10

You feel like you need to go to the emergency room


MEDICATIONS/SUPPLEMENTS

LIST the medications (including over-the-counter), that you are presently taking:

______________________ ______________________ ______________________

______________________ ______________________ ______________________

______________________ ______________________ ______________________
LIFESTYLE
CHECK any of the following feelings you have notably experienced in the last few months.
 Joy  Rejected  Cheerful  Fear  Anger

 Depression  Criticism  Guilt  Anxiety  Motivated

 Self-Confidence  Contentment  Grief  Paranoia  Assertive

 Sadness  Disappointment  Enthusiasm  Inner Direction  Irritable

 Loneliness  Confidence  Letting Go  Courage  Bitter

 Tranquility  Empathy  Apathy  Valued  Proud


Please CHECK the level of stress for the following:
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: ________  None  Minimal  Moderate  Severe


How much time do you have for relaxation and what do you do to relax (i.e., hobbies, meditation, etc.)?

_____________________________________________________________________________________

_____________________________________________________________________________________
Do you exercise?  Yes  No If so, what kind and how often?

_____________________________________________________________________________________

_____________________________________________________________________________________
How many hours a night do you sleep? ____ Is your sleep restful? ______If not, please explain:

_____________________________________________________________________________________

_____________________________________________________________________________________
Do you consider your diet healthy?  Yes  No If not, please explain:

_____________________________________________________________________________________

_____________________________________________________________________________________
Do you have concerns about your cognitive ability (focus, memory)?

_____________________________________________________________________________________


Are you content with your present weight?  Yes  No If not, please explain:

_____________________________________________________________________________________



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