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 GASTROINTESTINAL Face 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.
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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