Name
Date
Address
City
Postal Code
Phone Number
Email
Date of Birth
Occupation-s
Location of Birth
Time of Birth
Personal Physician
Health Goals
Weight Loss or GainLack of VitalityConfusionNervousnessIrritabilityDepressionInsomniaExcessive DreamingFeverSwollen GlandsNight SweatsNight UrinationSexual ProblemsBrittle/Soft Nails
Poor Short-TermPoor Long-Term
Chronic CoughFrequent ColdShortness of BreathNervousnessSinus PressureNasal CongestionExcessive MucusSores in MouthHoarseness of VoiceFrequent ColdsAllergiesExcessive SweatingBad BreathBad Breath
High Blood PressureLow Blood PressureHeart PalpitationsChest PainsChest DistensionIrregular Heart BeatVaricose Veins
Vision LossBlurry VisionDry/Red EyesExcessive TearingHearing LossRinging in earsEarachesPremature Hair Loss or GrayingHeadachesMigrainesDizzinessBlackoutsNeck PainJaw PainSwelling of faceFainting
Pregnant-due date__________(40wks)Breast TendernessBreast LumpsMenstrual PainBlood ClottingExcessive FlowDark BloodStrong SmellLength of Menstrual Cycle:____Days (28)Menopausal
TendonitisBursitisSprainsFracturesLower Back PainAching BonesMuscle TensionMuscle CrampsWeak MusclesNumbness/Tingling in ExtremitiesCold Hands/FeetSweaty Hands/FeetLeg SwellingJoint SwellingJoint Pain
Dry SkinItchingRashesChanges in MoleBurse EasilyOpen SoresLoss of sensation
Loss of AppetiteAbdominal PainsAbdominal DistensionBelchingPoor DigestionNausea/VomitingFatty Foods AggravateConstipationStrainingLoose StoolsDiarrheaThin StoolBloody/Black StoolsDaily Bowel Movements_____HaemorrhoidsFrequent UrinationBurning on UrinationBlood in Urine
Type
Year
For
Allergies:
Infectious Diseases:
How Often
How Long
Coffee
Tea
Alcohol
Cigarettes
White Sugar
YesNo
I certify that the information provided in this Health Status Form is true, and accurately reflects my past and present health status. I have been informed of biofeedback, stress and pain management procedure potential and I give my full informed consent to treatment. At any time, I have the right to ask Dr Charlene Reeves to modify or to stop the treatment.
To obtain the maximum benefit from treatments, it is important I provide feedback during and after the sessions. All client records are confidential. They will only be shared with other health care professionals, lawyers and insurance agents as allowed by Naramata Lifestyle Wellness Centre Privacy Policy to allow for your effective treatment.
I have read, understood and agree with all of the above.
Signature
