Confidential Health Inventory

Personal Information

Full name:

Date:

Address:

Zip code:

Home phone:

Work phone:

Cell phone:

Email address:

Best time/place to contact you:

Date of birth:

Age:

No. of children:

Are you pregnant?

Height:

Weight:

Marital status:

Spouse / guardian name:

Life Focus / Work:

Please list your health concerns according to their severity

Rate of severity
1 = mild
10 = worst imaginable

When did this begin?

Constant or Sporadic?

Did the problem begin with an injury?

% of the time pain is present

Do you experience physical pain? Does it radiate anywhere? If so, where?

Please list current Mental / Emotional / Spiritual health concerns?

Since the problem started, Is it:

What have you done to address your specified health concern? Has it helped?

What aggravates your pain or discomfort?

Other practitioners you have seen for this:

How are your health concerns or conditions interfering with your life?

General Health History

The accumulation of life’s stressors – physical, mental and emotional -- can lead to health problems and influence your ability to heal.

Have you had any surgery? (Please include all surgery)

Type

When?

Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems)

Type

When?

Hospitalised? Yes or No

Have you ever had x-rays or an MRI taken?

Area of the body:

When?

Where?

Your Self - Care Practices

Exercise, Meditation, Yoga, Prayer, Outdoors, Art-making, Tantra, EFT, Therapy, Massage, Specific Spiritual path…

Current Medicines and Supplements

Please list any medications/drugs you have taken in the past 6 months and why: (prescription and non-prescription). Include Covid-19 vaccines and boosters.

Nutritional supplements, vitamins, herbs, homeopathic remedies you presently take and why:

Food, etc.

Please choose any dietary selection that is appropriate for you, and grade according to the following scale:

D - Consume this daily | FD - Consume this a few times per day | W - Consume this weekly | FW - Consume this a few times per week

FM - Consume a few times per month (less than weekly) | M - Consume this monthly | O - Do not consume this

Which foods do you eat?

How often do you consume it?

The type of diet I usually follow is classified as:

Past Health History

On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:

Eating habits:

Exercise habits:

Sleep:

General Health:

Mind set:

How do you grade your physical health?

How do you grade your emotional/mental health?

Is there anything else which may help to better understand you, which has not been discussed?

What do you hope to achieve through receiving Body Energy Alignment?

I understand that Body Energy Alignment™ with Neesa Ginger Mills provides energetic, spiritual, and physical body support, and in no way promise to cure any specific disease or health condition.

Print name:

Signature

Date:

Parent / Legal Guardian Signature

Date:

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Personal Information

Health Concerns

Please list your health concerns according to their severity

Rate of severity
1 = mild
10 = worst imaginable

When did this begin?

Constant or Sporadic?

Did the problem begin with an injury?

% of the time pain is present

General Health History

Type

When?

Type

When?

Hospitalised? Yes or No

Area of the body:

When?

Where?

Your Self - Care Practices

Current Medicines and Supplements

Food, etc.

Which foods do you eat?

How often do you consume it?

Past Health History

Stressors

On a scale of 1-10, (1 being very poor and 10 being excellent) please describe your:

How do you grade your physical health?

How do you grade your emotional/mental health?

I understand that Body Energy Alignment™ with Neesa Ginger Mills provides energetic, spiritual, and physical body support, and in no way promise to cure any specific disease or health condition.