Confidential Health Inventory
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
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)
Have you had any accidents and/or injuries: auto, work-related, or other? (Especially those related to your present problems)
Hospitalised? Yes or No
Have you ever had x-rays or an MRI taken?
Area of the body:
Your Self - Care Practices
Current Medicines and Supplements
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?
Past Health History
Please list significant stressors and grade on a scale of 1-10; 10 being the highest possible.
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.
Thanks. Your confidential health history has been submitted
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