Name

First Name

Last Name

Birthdate / Birthplace / Age

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Marital status

Single

Married

Divorced

Widowed

Health Factors (Epigenetics Factors)

Identify your top 3-4 health (physical or emotional) issues or overall weaknesses you’d like addressed from most troublesome to least. Please include dates when each issue occurred and if it seems you are “locked” on this imbalance, no matter what you do or treatment you have.

Past medical history

Previous injuries, accidents, surgeries, etc. Please describe and include approximate dates

Medications / Suplements

List Medications, vitamins, supplements (including over the counter, herbal, homeopathic) you are presently taking.

Chemical Stressors

Do you regularly consume:

Alcohol

Recreational Drugs

Artificial Sweeteners

Refined Sugar

Caffeine

Tap Water

Tibacco

Past Traumas

Have you had any past experiences that still affect you deeply (trauma, accident, grief, vaccine, illness, etc.)?

Area of pain?

Please list areas of pain (i.e. right shoulder, left ankle/front side)

Area of Pain 2?

Please list areas of pain (i.e. right shoulder, left ankle/front side)

Diet

Prescribe your diet (simplify):

Exercise

Do you exercise? And if so, what kind and how often?

Intimacy and Sexuality

Is your relationship with your sexuality as great as you would like to?

Energy and Joy

What areas of your life give you joy and energy?

Celebration

What are wonderful things that you notice about your body?

What you imagine this session to look for you?

Informed Consent Policy

INFORMED CONSENT POLICY I understand that the BodyTalk session provided by this Advanced Certified BodyTalk PaRama Practitioner, is intended to enhance relaxation, increase communication within the areas of the body, and to educate me to the possible energetic or emotional blocks that may create pain and disease. BodyTalk is non-invasive, safe, and objective. It utilizes the body’s own innate intelligence to reestablish communication within itself. I understand that BodyTalk is not a substitute for medical treatment or medications. I am aware that the BodyTalk Practitioner does not diagnose illness or disease nor does the practitioner prescribe medications. PAYMENT AND CANCELLATION POLICY If you are unable to keep your appointment, kindly give 24 hours notice. Full payment will be charged for missed appointments. Payment is due at the time services are given. We reserve de right to charge a $30 fee for late payments and returned checks. I have read, understood and agreed to the above terms. Signature Date

Availability

We will take into consideration your information and will get back with some options for our next session.

Mondays - Mornings

Mondays - Afternoons

Tuesdays - Mornings

Tuesdays - Afternoons

Wednesdays - Mornings

Wednesdays - Afternoons

Thursdays - Mornings

Fridays - Mornings

Saturdays - Mornings