Client History

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Medical History form

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Date

First Name

Last Name

Contact number

Email

Date of birth

Occupation

Referred by

Briefly describe the health problem(s) you would like to resolve:

How long have you had the problem(s)?

Do you regard your health problem(s) to be:

Severe?

Quite Severe?

Moderate?

Mild?

What other forms of therapy have you used to resolve your health problem(s)?

Diet

Physiotherapy

Chiropractic

Allopathy

Supplements

Acupuncture

Osteopathy

Other (please state)

Please give details of the therapy used

How successful were they?

Very successful

Slightly successful

Quite successful

Not successful

Do you have any specific illness or problems recurring from time to time - (ie. rashes, premenstrual pain, sleeplessness,/insomnia, shortness of breath, migraines, constipation, dyspepsia, cystitis, incontinence, infections, coughs, colds….. etc)?

Give details and any medications used

Do you have any ongoing disease(s) - (ie. asthma, hypertension, diabetes, arthritis, cancer, coronary heart disease, ulcers…etc.)?

Give details and any medication used

Please list previous/other: illness/accidents/surgery that you have had and the year in which it occurred:

Do you take any of the following?

Herbs

Flower Essences

Coffee

Amino Acids

Artificial sweeteners

Vitamins

Minerals

Food additives

Anti-oxidants

Antacids

Homeopathics

Birth control pill/HRT

Tinned or processed foods (regular basis)

Do you have any allergies? If yes, please state:

What is your daily water intake? (not including fruit juice, soft drinks, tea, coffee)

2 litres

1 litre

500ml

less

Breakfast

Lunch

Dinner

Snacks

What are your favourite foods?

Are your bowel movements:

daily?

less than daily?

How often do you exercise?

daily?

weekly?

occasionally?

never?

On a scale of 1 - 10 what is your daily energy level?

Are there any problems/stress factors in your life at the moment?

My stress levels at the moment are:

High

Quite high

Middling

Low

My working situation is:

Very Good

Good

Not good

Poor

My living situation is:

Very Good

Good

Not good

Poor

Relaxation/meditation

None

Occasionally

Often

Daily

Smoker?

Were you a smoker?

Yes

No

From when to when?

Was your birth

Normal

Induced

Caesarean

Do you use orthotic appliances in your shoes?

Yes

No

Do you experience back or neck pain or other physical pain?

Yes

No

Please give details

Do you experience ringing in the ears, clicking/popping of the jaw or facial pain?

Yes

No

Please give details

If you are female: Are you pregnant?

Yes

No

How many weeks?

Duration of menstrual cycle

Click all that apply

Regular

Irregular

Painful

Heavy

Pre-menopausal

Menopausal

Please choose all of the following issues which relate to you:

Nervousness

Sexual Problems

Finances

Anger

Stress

Tiredness

Energy

Concentration

Career choices

PMS

Muscle Pain

Back pain

Neck pain

Joint pain

Other pain

Regrets

Guilt

Tinnitus

Depression

Suicidal thoughts

Drug use

Self-control

Work

Legal matters

Insomnia

Making decisions

Inferiority

Unpleasant memories

Enemies

Anxiety

Trust

Fears

Separation

Alcohol use

Unhappiness

Relaxation

Memory

Loneliness

Temper

Marriage

Repetitive thoughts

Communication skills

Dizziness

Infertility

Bed wetting

Shyness

Divorce

Friends

Sleep Apnoea

Headaches

Ambition

Education

Nightmares

Children

Parenting

Motivation

Grieving

Please choose which of the issues you would like to deal with in our work together:

Nervousness

Sexual Problems

Finances

Anger

Stress

Tiredness

Energy

Concentration

Career choices

PMS

Muscle Pain

Back pain

Neck pain

Joint pain

Other pain

Regrets

Guilt

Tinnitus

Depression

Suicidal thoughts

Drug use

Self-control

Work

Legal matters

Insomnia

Making decisions

Inferiority

Unpleasant memories

Enemies

Anxiety

Trust

Fears

Separation

Alcohol use

Unhappiness

Relaxation

Memory

Loneliness

Temper

Marriage

Repetitive thoughts

Communication skills

Dizziness

Infertility

Bed wetting

Shyness

Divorce

Friends

Sleep Apnoea

Headaches

Ambition

Education

Nightmares

Children

Parenting

Motivation

Grieving

Is there anything else in your life that you would like to:

stop doing?

start doing?

do better?

do differently?

Please briefly explain

Is your mother still alive?

Yes

No

Do you know their cause of death?

Is your father still alive?

Yes

No

Do you know their cause of death?

Does a chronic disease like diabetes, hypertension, cancer, arthritis etc run in your family?

Yes

No

Do you have children?

Yes

No

How old are they?

If not healthy, please give details

Are they healthy?

Yes

No

Please give details

Do you have a support person/group?

Yes

No

Is there any other relevant information regarding your health and/or disease you want to mention?

I consent to have this organisation store my submitted information. For regulatory purposes it is necessary to keep these details for 7 years after the end of therapeutic sessions.

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