Health Questionnarie

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D.O.B:*

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Email*

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Phone*

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About Your Health:

The human body is designed to be healthy. Throughout life, events occur which damage your health expression.

This case history will uncover the layers of damage, especially to your nerve system, which have resulted in poor health.

On this weekend we will begin to correct these layers of damage and recover your innate health potential.

Loss of Wellness (Birth – Age 5)

Let’s begin at birth when you may have ﬁrst damaged your nerve system, lost your wellness and began your journey to ill health.

Birth Process

Was the delivery long and/or diﬃcult?*

Yes

Comments (Was the delivery long and/or diﬃcult?)*

Were Forceps or suction used?*

Yes

Comments (Were Forceps or suction used?)*

Was the birth Cesarean?*

Yes

Comments (Was the birth Cesarean?)*

Breech / Cephalic?*

Yes

Comments (Breech / Cephalic?)*

Do you know of any stressful situation that may have been present for your mother or father or both?*

Growth and Development

Did you roll out of bed or have any falls as a child?*

Yes

Childhood illnesses?*

Yes

Did you have other traumas?*

Yes

What?*

When?*

Did you have colic, reﬂux or diﬃculty feeding?*

Yes

Were there any stressful events that occurred in this time?*

Yes

Loss of Whole Body Health (Age 5 – Present)

As you increase the layer of damage you probably begin to experience symptoms and random bouts of sickness.

Did you / Do you smoke?*

Never

Reformed smoker

Daily

Do you / Do you drink Alcohol?*

Never

Did previously

Weekly

Daily Did you / Do you take recreational Drugs?*

Never

Did previously

Weekly

Daily

Have you recently taken recreational drugs? Please list them along with no of days/weeks since taking.*

Do you take over the counter Drugs? (Prescriptive or Non-prescriptive)*

Never

Have Recently

Currently Taking

If you have recently taken prescription drugs? Please list them along with no of days/weeks since taking.*

Please include the drug function for eg, blood pressure, anti-arthritis etc

Will you continue to take this medication During the retreat?*

Never

Have Recently

Currently Taking

If choosing to discontinue drug therapy whilst on the retreat, please discuss this with your doctor first.

Diet (do you eat healthy?)*

Yes, Always

I try to eat Healthy

Have you been in any Accidents?*

Yes

Specify*

Have you had surgery and organs removed or replaced?*

Yes

Sleeping habits?*

Yes

Trouble sleeping, sleep debt, wake up tired etc

Sleeping Posture:*

Side

Stomach

Back

Did you / Do you have Occupational stress?*

Yes

Physical and/or Mental stress?*

Yes

Hobby / Sports injuries?*

Yes

Present State of Health (Symptoms)

What is your body telling you right now? What symptoms are you experiencing? Please explain and describe what is happening in your body*

When did this start?*

What do you think the cause is?*

What activities aggravate your condition?*

Is this condition interfering with:*

Work

Sleep

Routine

Other

What is this stopping you from doing?*

If this were to go away tomorrow, what would be diﬀerent about your life?*

Are you living the life you would like to be?*

On a scale of 0-10, how happy are you?*

On a scale of 0-10, how much stress is in your life?

Are you ready to make changes to your life in order to heal, even if these changes are inconvenient to your lifestyle?*

Any Other Symptoms you are experiencing*

Please tick if applicable

Neck Pain

Stiﬀ Neck

Third Choice

Headaches

Dizziness

Fainting

Ears Ring

Balance Loss

Numb Toes

Chest pain

Fever

Loss of Memory

Migraines

Thyroid Issues

Sciatica

Numbness in Fingers

Shoulder Pain

Cold Feet/Hands

Loss of smell/Taste

Cold / Flu

Allergies

Pain in Mid-spine

Cold Sweat

Hearing problems

Lights bother eyes

Menstrual Pain

Stress

Not Sleeping

Fibromyalgia

Nervousness

Tension & Irritability

Fatigue/Sleeping problems

Depression

Chronic Fatigue

Pins & Needles / Legs

Shortness of Breath

Weight Problems

Stomach/Digestive Problems

Constipation/Diarrhea

Pins & Needles in Arms

Diﬃculty Breathing

Lower Back Pain

Knee Pain

What are you looking to get out of these sessions?*

Have you had any trauma or abuse in your life?*

Please let us know in a few sentences, how we can assist you and help you the most?*

By signing this form, I agree and consent to the healing work.

I understand that with any healing process and work on my body, my symptoms may worsen before they get better.

I understand this care is designed to assist the body with healing by helping to remove stressors from the body. I understand that healing takes time and there is no quick immediate ﬁx to my problem, and health is a process.

I have freely decided to undergo the recommended treatment and hereby give my full consent to treatment.

Signature*

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About Your Health:

Loss of Wellness (Birth – Age 5)

Birth Process

Growth and Development

Loss of Whole Body Health (Age 5 – Present)

Present State of Health (Symptoms)

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Therapeutic Services

For Institutions

Practical Information

Health Questionnarie

About Your Health:

Loss of Wellness (Birth – Age 5)

Birth Process

Growth and Development

Loss of Whole Body Health (Age 5 – Present)

Present State of Health (Symptoms)

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