HEALTH PROFILE – BCT + Acupuncture

Biodynamic humanBEing





Phone: Cell/Landline (circle one):_________________________________

Date of Birth:________________Age:_____________________________

How did you hear about my office and services?_____________________

Do you have any health/life concerns?_____________________________

Do these concerns affect your life?_____________

How? Circle what applies – Work Family Relationships Hobbies
Life enjoyment Relaxation Other:_____________________________

If you didn’t have these concerns how would your life be different?____________________________________________________________

PHYSICAL TRAUMA HISTORY- circle what applies

Forceps delivery        Falls of any type         Broken bones           strains/sprains

Poor posture         poor sleeping habits               repetitive movements

Sports injuries         heavy lifting/bending       overweight            auto accident


CHEMICAL STRESS – circle what applies

Prescription medication           Over the counter drugs          Marijuana

Alcohol       Tobacco          ecigarettes             eat fast food

artificial sweeteners        white flour/white sugar           processed food

Exposed to environmental pollution         Overweight              Allergies


EMOTIONAL STRESS – circle what applies

Divorce – parents or spouse          Death of a loved one            Serious illnes –
self or loved one

Financial concerns      Worry        Work environment             Relationships

Anger by you or at you              Feel “not worthy”            Put things off to the last

Which of the 3 types of stress has had the greatest impact on your well being and why?



Please list any past medical history including – surgeries, procedures, medical diagnoses…________________________________________________________________________________________________________________________

Have you ever had any problems/diagnosis/treatment for any of the following? circle what applies

Skeletal System – Bone conditions…

Muscular System – Muscles, tendons, ligaments, joint pain, neck pain, back pain > upper, middle, lower, arms, legs, shoulder, feet, jaw

Respiratory System – Lungs, Bronchial tubes, Pulmonary problems, chest pain, difficulty breathing, other…

Digestive System – Stomach, intestines, pancreas, gall bladder, liver, heartburn, diarrhea/constipation, digestion problems, other…

Nervous System – Seizures, poor memory, lack of coordination, other

CardioVascular System – Heart, cardiac vessels, hypertension, blood
vessels, other…

Urinary System – Kidney, bladder, infections, other

Reproductive System – Uterus, ovaries, fallopian tubes, cervix, prostate

LymphImmune System – frequent infections or colds

Integumentary System – skin disorders

Endocrine System – Pituitary, Pineal, Hypothalamus, Thyroid, Parathyroid, Thymus, Adrenals, Pancreas, Ovaries/Testes



Do you exercise? If so, what do you do and how often?

Do you meditate? If so, how often?

Do you do a spiritual practice?

Do you receive any other healing work regularly? If so, what kind and how often?

Do you get out in nature often?

What foods do you eat most often?

What diet do you follow? Vegan – Vegetarian –  Non-vegetarian    Fast Food,  Other…

Are you willing to change? If not, you might consider seeing another practitioner.

What are your Goals/Expectations for seeking care at this office?


Do you understand that my practice isn’t about symptom care or pain relief but is about freeing your Life Force to activate optimal health and well being?      Yes                No


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