Basic Information

Email Address

Phone Number

Address

Please provide a general region or country of residence with as much specificity as you feel comfortable with.

Year of Birth

Select

Please select which option relates to yourself

Referral Name

If you have been referred by someone, please name the person below:

Part One: Health

Please answer all questions honestly and to the best of your ability.

Describe the problems for which you seek help

(include physical symptoms, emotional states, or life circumstances when symptoms initially occurred)

What happened in your life just before these issues occurred?

Please describe your relationship with your family from when you were a child and now.

Other relationships (friends, co-workers etc.)

Past medical history (previous injuries, accidents, surgeries, etc.)

Current Medication?

What daily activities are you finding difficult or are limited because of your above complaints?

Have you ever had this problem before, and if so when?

Please list any other kind of healthcare professional you are seeing for this/these problem(s).

Are other areas of your life contributing to your stress?

How much time do you have for yourself to relax and what do you do to relax?

Do you exercise? What type and how often?

How many hours a night do you sleep?

Is your sleep restful? If not, please explain

Any other information that may be useful?

Part Two: Pain Levels

Please list areas of pain and best describe the level of discomfort on a scale of 1 to 10. 1. Slight awareness of discomfort. 2-3. Awareness of discomfort as an aggravation. 4-6. Pain is strong but you are still functional. 7-9. Pain is so strong you are unable to function normally. 10. You feel like you need to go to the emergency room.

1. Body Area

2. Body Area

3. Body Area

4. Body Area

5. Body Area

Part Three: Consent

By filling the information below, I accept and understand the following: I understand that the PaRama BodyTalk session provided by Angie Tourani is intended to enhance relaxation, increase communication within areas of the body, and to educate me to possible energetic or emotional blocks that may create pain and disease. I acknowledge that BodyTalk is non-invasive, safe and objective. It utilizes the body's own innate intelligence to re-establish communication within itself. I understand that the BodyTalk System is not a substitute for medical treatment or medication. I am aware that the BodyTalk practitioner does not diagnose illnesses or diseases nor does the practitioner prescribe medication. I understand that all information shared during the session is educational in nature and is intended to help me become more familiar and conscious of my own health status and is to be used at my own discretion. It is confidential and is treated as such. By providing this consent, I am assuming full responsibility for my BodyTalk sessions and hold harmless both the practitioner and the facility / location where the session is provided. I understand that I may experience so-called "detoxification symptoms" or releases during the next 24-72 hours following a session and that these may be somewhat uncomfortable, particularly if I have been experiencing chronic or heightened levels of stress.

Tell angie more about your

Health History

Contact Angie Tourani:

T: +852 6683 5755
E: ANGIE@BODYTALKSYSTEM.COM.HK