Health History Form – Innate Healing

Skip to content

BODY STRESS RELEASE
ASYRA BIO-RESONANCE
MIGUN BED
TESTIMONIALS
HEALTH HISTORY FORM
ABOUT
CONTACT

PLEASE FILL IN THIS HEALTH HISTORY FORM

I will print it out and keep it on file. This will give me an overview of what you have experienced in the past and what is presently happening in regards to your health. At your first session, we will discuss these items and put into place a plan towards your well-being.

Please enable JavaScript in your browser to complete this form.

Name *

First

Last

Date of Birth

Email *

Address

Phone number

How did you find out about my BSR practice?

Are you righ-handed or left-handed?

Right
Left

Current occupation?

As a means of determining existing stress patterns, please list previous jobs if your current one has come about recently

Main health concerns that you presently would like addressed:

Are you currently under emotional stress?

Yes
No

Recent or past traumatic events

Please list all physical trauma within memory – including year:

Examples: Fractures/broken bones operations/fusions/metal plates, accidents bad falls, whiplash

Do you have frequent headaches?

Yes
No

Do you suffer from migraines?

Yes
No

If yes – how often? Do you know what triggers this?

Do you have frequent nausea?

Yes
No

Do you suffer from dizziness?

Yes
No

Digestion trouble?

Yes
No

Trouble with urination?

Yes
No

Trouble with constipation?

Yes
No

Do you presently take any pain blocking meds?

Yes
No

Any pres-existing disease(s) or condition(s)?

Legs/feet/toes

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Arms/hands/fingers

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Lower back

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Sciatica/buttons area

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

physical – list

Chest/abdomen/pubic area

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Middle back/ between shoulder blades

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Neck/head/jaw/top of shoulders/face

Please list any and all pain or discomfort. If it is presently happening, is it constant or on/off? ** If it is no longer present – when did it last appear? **

Do you wish to address any fertility/sexual dysfunction issues?

Yes
No

Do you sleep soundly through the night?

Yes
No

Which position do you tend to sleep in?

(R side, L side, Back, Stomach)

Sports activities

Exercise(s)

Hobbies

Any additional health related informtation