Health And Well Being History Form

Name Address Home Phone Cellular Phone Date PART 1. * Please answer the following questions honestly and to the best of your ability. Describe the problem(s) for which you seek help. Please include dates when each problem occurred: Past medical history (previous injuries, accidents, surgeries, etc. Please describe and include approximate dates List the medications (including over the counter) you are presently taking What daily activities are you finding difficult or are limited because of your above complaints Have you ever had this problem before, and if so when What are your goals from BodyTalk Please list any other kind of healthcare professional you are seeing for this/these problem(s) Please list any medical tests you have had within the past year * Please circle any of the following feelings you have experienced in the last few months.  Abused   Criticized   Overworked   Paralyzed   Depressed   Rejected   Despair   Helpless   Hopeless   Paranoid   Overwhelmed   Muddled   Persecuted   Guilty   Easily irritated   Anxious   Sad   Grieving   Unable to grieve   Apprehensive   Agitated   Uneasy   Distress   Fearful   Impatient   Intimidated   Restless   Panic   Intolerant   Uncertainty   Aggravated   Annoyed   Angry   Outraged   Nervous   Worried  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 is  None   Minimal   Moderate   Severe  How much time do you have for yourself to relax and what do you do to relax, ie. hobbies, meditation, etc ? PART 2. * Please list areas of pain and mark the circle that best describe the level of discomfort on a scale of 1 to 10. 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. Pain Area Level of Discomfort 1 2 3 4 5 6 7 8 9 10 Pain Area Level of Discomfort 1 2 3 4 5 6 7 8 9 10 Pain Area Level of Discomfort 1 2 3 4 5 6 7 8 9 10 Pain Area Level of Discomfort 1 2 3 4 5 6 7 8 9 10 Do you exercise? And if so, what kind and how often? How many hours a night do you sleep? Is your sleep restful? f not, please explain: Please enter text Refresh

Please register on www.bodytalksystem.com as well as this form below.

Register early, as student numbers are limited to optimize learning
Instructor:__Terryann Nikides
Coordinator – Angie Tourani – contact 852 668357455 or angie@tourani.com

Credit Card facility is available only for payment till end April.Note: No personal cheques within 30 days of the seminar/workshop.

Cancellation Policy

Anyone cancelling registration for trainings prior to 30 days of the workshop date will receive a full refund; anyone cancelling within the 30 day deadline will not get a refund but will be able to take the course with Terryann Nikides at another scheduled course date.

Banking Details – BodyTalk Life Therapy co. HSBC A/C number – 817-157027-838Print registration form, then complete and mail it along with your payment to: angie@tourani.com or Fax 2259 3462

Forms

• BodyTalk Access Registration Form
• BodyTalk System Mod 1&2 Registration Form
• BreakThrough 1 Registration Form
• Health History Form
• Public Presentation Registration