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Body Flow client intake form

If you are not sure, please don't answer.

Birthday
Day
Month
Year

Birth

Was your birth difficult or long?
Yes
No
Was the birth Cesarean?
Yes
No
Was your mother given any drugs during delivery?

Growth and development

Did you roll out of bed or have any falls as a child?
Yes
No
Did you have any childhood illnesses?
Yes
No
Did you have any other childhood traumas?
Yes
No
Did you have colic, reflux or difficulty breathing?
Yes
No
Were there any stressful events that occurred in this time?
Yes
No

Ages 5 to present

Did you or do you smoke?
Yes
No
Do you drink Alcohol?
Yes
No
Do you take recreational drugs?
Yes
No
Do you take over the counter Prescriptive or Non Prescriptive Medication?
Yes
No
Do you eat a healthy diet most of the time?
Yes
No
Have you been in any accidents?
Yes
No
Have you had surgery and organs removed or replaced?
Yes
No
Do you have occupational stress?
Yes
No
Do you have any sports injuries?
Yes
No
Do you have physical and or mental stress?
Yes
No
Do you have any...
Brain fog
Chronic fatigue
Tinitus
Teeth problems
Sinus problems
Vertigo

Present State of Health Symptoms

On a scale of 1 - 5 how happy are you, with 5 being the happiest?
On a scale of 1 - 5 how much stress is in your life with 5 being the highest?
Do you have any of the following symptoms?

Please tick the following that applies to you:

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