Confidential Client Information
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PLEASE PRINT -- THANK YOU
Today’s Date __________________________________________________________________________________
Name _______________________________________________________________________________________
Mailing Address _______________________________________________________________________________
City, State, Zip ________________________________________________________________________________
Phone to leave confidential message (_________) _________________________________________________
Email Address _______________________________________________________________________
Age ___________ Birth date (optional) _____________________________
Occupation __________________________________________________ How long? ______________________
Emergency Contact (someone who can come and get you if needed):
Name _____________________________________________ Phone (_________) _____________________________
1) Briefly describe why you are coming for our work now. What is your intention for our work?
2) Health History:
PLEASE NOTE: This information is confidential and useful in our work together. However,
please let me know if you prefer not to disclose any of the following.
(a)
ACCIDENTS (eg, fall, vehicle/bike collision, etc.) - INCLUDE 'major', 'minor', & childhood.
INJURIES (eg, muscle sprain/strain, repetitive motion injury, etc.) - INCLUDE 'major', 'minor', & childhood.
SURGERIES - INCLUDE Oral Surgeries, 'major', 'minor', & childhood.
b) Please indicate your experience with other healthcare practices (not including your work with
me). Details can be provided on additional (blank) pages if needed.
REHAB BODYWORK (Physical Therapy, Chiropractic, etc.)
How many times per year do (or did) you use this service or practice?
6+ times per year
1-6 times per year
Never
Not sure/Other: ____________________________________________
How long do (or did) the effects of a session last before you notice symptoms return?
3+ days
1-3 days
less than 1 day
Not sure/Other: ____________________________________________
Did/do you notice positive results or changes?
Yes
No
Not sure/Other: ____________________________________________
Do you plan to continue this practice along with our work?
Yes
No
Not sure/Other: ____________________________________________
RELAXATION/THERAPEUTIC BODYWORK (Massage, Energy work, TaiChi, etc.)
How many times per year do (or did) you use this service or practice?
6+ times per year
1-6 times per year
Never
Not sure/Other: ____________________________________________
How long do (or did) the effects of a session last before you notice symptoms return?
3+ days
1-3 days
less than 1 day
Not sure/Other: ____________________________________________
Did/do you notice positive results or changes?
Yes
No
Not sure/Other: ____________________________________________
Do you plan to continue this practice along with our work?
Yes
No
Not sure/Other: ____________________________________________
EMOTIONAL/MENTAL HEALTH (Psychotherapy, Support Group, etc.)
How many times per year do (or did) you use this service or practice?
6+ times per year
1-6 times per year
Never
Not sure/Other: ____________________________________________
How long do (or did) the effects of a session last before you notice symptoms return?
3+ days
1-3 days
less than 1 day
Not sure/Other: ____________________________________________
Did/do you notice positive results or changes?
Yes
No
Not sure/Other: ____________________________________________
Do you plan to continue this practice along with our work?
Yes
No
Not sure/Other: ____________________________________________
SPIRITUAL DEVELOPMENT (Religious practice, Yoga, Meditation, etc.)
How many times per year do (or did) you use this service or practice?
6+ times per year
1-6 times per year
Never
Not sure/Other: ____________________________________________
How long do (or did) the effects of a session last before you notice symptoms return?
3+ days
1-3 days
less than 1 day
Not sure/Other: ____________________________________________
Did/do you notice positive results or changes?
Yes
No
Not sure/Other: ____________________________________________
Do you plan to continue this practice along with our work?
Yes
No
Not sure/Other: ____________________________________________
c) Are you currently or recently experiencing any physically or emotionally stressful
events (e.g., loss/grief, traumatic event, chronic pain/stress/anxiety/tension, etc.)?
If yes, please describe:
d) Are you pregnant or trying to become pregnant? Have you experienced miscarriage or
other terminated pregnancy?
e) Are there any other physical or emotional conditions I should be aware of (e.g.,
arthritis, migraines, high blood pressure, epilepsy, etc.)? If yes, please describe
(including if you are under a doctor’s care and/or taking medications for the condition):
3) Is there anything else that you would like to share with me now?
Thank you
CONFIDENTIAL
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