Body Story Inventory

Before you start we need to some basic contact information.

Sit back, relax, and get present in your body. It can take about 20 minutes to complete this form, and it is well worth your time. Fill out as much as you can. This information will help us make the best use of our time in your consultation.

Question - 1

Where do you hold tension in your body? List location, describe the sensation and length of time you have experienced the feeling (if known).

EXAMPLE:

a. Both hands and fingers for 5 years, prickly feeling and tightness.

b. Low back stiff and has burning sensation 1 month (pulled a muscle at work).

Question - 2

Where do you have a dis-ease or where do you have a vulnerability to dis-ease? How often does this symptom appear, or is it chronic?.

EXAMPLE:

Bronchitis in lungs, reoccurring usually every 6-8 months.

Question - 3

Are you ticklish? If yes, what areas do you end to feel ticklish? How long have you experienced this?

EXAMPLE:

Left side, from age 6 to present.

Questions - 4a to 4j

For questions 4a through 4j, describe what you feel in your body when you imagine these significant relationships in your life? Hold one person in mind at a time. Notice your breathing, heart rate, tension, sensations and emotion. Take your time to notice the location where you feel things in your body.

Describe your awareness of some of the following significant relationships of your life (living or deceased):

EXAMPLE:

Brother:
My heart rate raises some, subtle tension in belly, a feeling of sadness.

Question - 4a

Spouse/partner relationship:

Question - 4b

Boss/employee/team assistant/colleague:

Question - 4c

Mother:

Question - 4d

Father:

Question - 4e

Siblings:

Question - 4f

Chosen family member(s):

Question - 4g

Teacher (s) :

Question - 4h

Pet:

Question - 4i

Spirit (however you define that):

Question - 4j

Other

Question - 5

What do you feel in your body when you pay your bills (or when you think about your bills being paid by an assistant)? Again, notice what are the sensations, awareness and location of these feelings as you imagine this activity.

Questions - 6a to 6g

Feeling of Safety. In questions 6a-6g below, select the sentence that best describes your feeling of safety in the following areas:

Question 6a

How safe do you feel in your world?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6b

How safe do you feel in your home?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6c

How safe do you feel in your business?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6d

How safe do you feel while traveling?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6e

How safe do you feel in your significant relationship?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6f

How safe do you feel in your sexual/erotic relationship?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 6g

How safe do you feel in your spiritual community?

I don't feel safe.
I feel somewhat safe.
I feel safe.
I feel very safe.

Question 7

Do you already do some form of body care, body therapy or energy work? Check those you are doing (within the past two months).

Yoga
Tie Chi
Chi Gong
Watsu
Reiki
Massage
Feldenkreis
Erotic Body Therapies
Aerobic exercise
Weight-bearing exercise
Breathwork
Acupuncture

Other
Other

Question 8

Do you have an addiction or a tendency towards addictive behavior? Ckeck the one or those that apply.

Food
Drugs
Alcohol
Money/Gambling
Shopping
Sex
Other
Other

Question - 9

What do you feel in your body when you think about this addiction?

Question - 10

Have you ever been emotionally, physically or sexually abused? Abuse may also be defined in non-direct terms like neglect or verbal abuse etc. What do you feel in your body when you think about his/these experiences?

Question - 11

What do you feel in your body when you imagine being free of any emotional blocks?

Question - 12

What do you feel in your body when you are afraid or when you are approaching conflict?

Question - 13

When you experience compassion, what do you feel in your body?

Question - 14

What does it feel like to be powerful in your body? Where do you feel it?

Question - 15

In what area(s) of your life do you want to experience more abundance?