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Which of the following symptoms have you been experiencing?Check all that apply even if they have occurred only once since 1988
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Headaches,if so where? |
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back of head |
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base of skull |
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forehead |
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cluster headaches |
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migraines on the left side |
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migraines on the right side |
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ocular migraine (pain begins at the back of the head and travels in a line up and over the head & circles one eye) |
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received impact to head of any kind e.g. whip lash, horse riding fall, concussion even prior to 1988 |
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neck pain |
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shoulder pain |
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muscle aches or joint aches |
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numbness, if so where? |
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tingling, if so where? |
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loss of grip |
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deep leg jerks and pain |
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vibrating while meditating or while falling asleep |
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tones, beeps, music, or “electronic Morse code” in your ears |
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blurry vision |
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double vision |
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hazy vision |
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objects appearing to melt, shimmer, or move |
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seeing geometries, equations, bands of light, hieroglyphics, or fire letters in external or internal vision |
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dizziness |
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“hot flashes” |
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flu-like symptoms |
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changes in food habits |
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excessive sensory input |
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memory loss |
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inability to project forward in time |
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inability to communicate in sentences |
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inability to comprehend what others are saying (audio dyslexia) |
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heart palpitations, arrhythmia, chest pains |
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clumsiness |
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free floating anxiety |
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sudden sense of being “lost” |
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sudden inability to make decisions |
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seizures |
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intense déjà vu, If so how often? |
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displacement: for a few seconds you are somewhere you have been before with full sensory experience,so strong you can smell the coffee. If so how often? |
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body jerks while drifting off to sleep |
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shake when you wake up |
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so cold on the inside of your body that your teeth chatter, even though the room is warm |
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cold hands and feet |
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hiatal hernia and/or acid reflux |
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difficulty digesting food |
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low level irritation or depression |
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extraordinary pain when you stub your toe |
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extreme panic feeling over a particular creature(e.g. snakes, spiders, bugs) |
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coughing |
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pressure on the chest and forehead with tingling and numbness in the hands and arms |
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deep fatigue, especially upon waking up in the morning |
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Headache in centre of head and/or radiant headache at jade pillow that can feel like a metal plate has been screwed to it. |
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a feeling of wanting to die/leave the planet |
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allergies/arthritis |
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hypersensitivity |
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feeling like an alien |
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big change in personality/personal preferences |
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Is there anything else you think your practitioner should know?
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| I understand that healing is not a medical treatment. I also appreciate that it is my responsibility to seek medical care for any problem or illness. |
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