Biofield Therapeutics Questionnaire

The purpose of this questionnaire is to help suffering persons identify possible root causes of physical, mental and emotional symptoms. 

Name ___________________________           Date of birth __________           Today’s date________

 

Please explain your current chief complaint or symptoms:

MEDICAL HISTORY

Have you received formal diagnoses of any kind?

Do you have a chronic physical pain or illness that won't go away, or that Doctors cannot seem to cure?

Have you ever been under general anesthesia?  What for? When?

Have you ever lost a child, born or unborn? If so, when?

Have you been told you have a hereditary disease?   What is it?

MENTAL HEALTH HISTORY

Do you suffer from anxiety or panic?

Have you been diagnosed with another psychiatric or mood disorder? Please explain.     

Do your moods change quickly for no apparent reason?

Do you have memory loss?

Do you have intrusive thoughts or feelings?

Do you ever feel that you are not alone?

Over time, have you developed addictions to food, alcohol, drugs or behaviors you didn't have before?

Have you ever used drink or drugs to the point of blackout (walking and talking, but not remembering a period of time)?

Have you ever used drink or drugs to the point of unconsciousness?  List dates the best you can.

Do you hear thoughts in your head that are not yours?

Do you see people or things that others cannot?  If so, please describe

Are you or have you ever felt suicidal?

History of Traumatic Experience

Have you been involved in loss-of-life events? When?

Has a loved one died, who had symptoms, personality changes, habits, addictions like yours?

Have you been a victim of a violent crime?

Do you see a cycle of victimization in your life?

Did you suffer physical, sexual or emotional abuse?            When?

Were you ever tortured physically, mentally or emotionally?       When?

Behavioral

Are you accident prone or clumsy? If yes, please explain

Do you sustain recurring injuries or symptoms in the same area of your body? (Ex: always bumping your head, always twisting your right ankle, always have a stomach ache, etc). Please explain.

Do people ever say that you did or said something, but you have no recollection of doing or saying it?

Has anyone ever said that you talk in your sleep?

Do you have insomnia?

Did you suddenly lose your attraction to your mate, or decide to change your sexual orientation?

Do you feel repulsed by people of the same or opposite sex?

Have you had a dramatic change in attitude or beliefs?

Have you ever engaged in self-destructive behavior – cutting your skin or hair, picking at your skin or face, battering yourself or other things?           When?

Circumstantial

Did your mother ever lose a child that you know of?  If so, when?

Were you a twin, but the other baby didn’t survive?

Do you know anyone who has committed suicide?  If so, who and when?

Are any of your symptoms similar to those of a deceased family member or loved one?

Do you feel like someone has hexed you, or put a curse on you?

Environmental

Have you ever toured or lived near or fought in a battlefield or place of extreme decimation of human life?

Do you experience paranormal activity in your home? Please explain.

Do you live near or spend time in a cemetery for any reason?

Do you live near a hospital, convalescent home, funeral home, church, etc?

Have you spent time in a hospital, prison, convalescent home, treatment center - for work, to visit, or other reasons? When?

Other

Is there anything else you’d like me to know?