Name:                                                                                          Date:

Email :                                                                               Occupation :

Address:

Height :                  Weight :                                           Date of Birth :

Phone Home :                                                 Phone Work :                            

Emergency Contact (name & phone):

Relationship Status:                      # Children :              Ages :                   

Physician (name & phone):

Therapist (name & phone) :

Reason for Visit (add details on back if necessary) :               

Current/Previous Treatment (for reason for visit) :

Current Medications :

Current Complementary Therapies/Supplements :

Eating Habits/Diet :

Amount Daily Intake:
Water:                  Caffeine:                  Alcohol:                    Cigarette/Tobacco:

Exercise routine :

Vision:- Wear glasses/contacts             Smell:             Hearing:                   Taste:

Please mark the following areas of disease or symptoms as “C” – current, “P” - past, “O”– occasional and “CH” - chronic.Explain if necessary.

• Please list any injuries you have had and have presently:

• Please list any surgeries you have had or know you will have:

• Please list any traumatic, or life threatening events that occurred in your life, and when they happened: (ex. Separation, divorce, deaths, depressions or other significant event) :

• What do you hope for and what are your expectations from this healing today and long-term:

• What is your connection with spirituality (religious background, development, current practice):

• Brothers/sisters                                                                           Rank in family:

• Relationship with mother:

                  - As a child:

                  - Present:
 

• Relationship with Father:
  
          - As a child:
  
          - Present:

• General (further details on reason for visit or anything else you want to share or want me to know):