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Client History Personal Lifestyle Presenting Condition

This document contains a client intake form collecting personal and medical history information. It requests the client's name, date of birth, address, contact details, occupation, marital status, children, hobbies, medical history including surgeries/injuries and health conditions, medications, supplements, diet, exercise, and presenting health concerns. For female clients, it additionally inquires about contraceptive use, pregnancy status, menopause, and energy levels. The form is intended to clarify the client's needs and ensure their information is kept confidential.

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Scott
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110 views1 page

Client History Personal Lifestyle Presenting Condition

This document contains a client intake form collecting personal and medical history information. It requests the client's name, date of birth, address, contact details, occupation, marital status, children, hobbies, medical history including surgeries/injuries and health conditions, medications, supplements, diet, exercise, and presenting health concerns. For female clients, it additionally inquires about contraceptive use, pregnancy status, menopause, and energy levels. The form is intended to clarify the client's needs and ensure their information is kept confidential.

Uploaded by

Scott
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Client name - _______________________________________________ D.O.

B ___/___/_____ Age - ______


Address -_________________________________________________________________ P/code - __________
Mobile no.__________________________ Email address_____________________________________________
Occupation_____________________________________________________ Today’s date _________________
Marital Status _________________ Children __________________
Sports / Hobbies ______________________________________________________________________________

Client History Personal Lifestyle Presenting Condition

1.Have you undergone any surgery 1.List medications you take regularly. 1.Briefly describe the health problems
or injury in the last year?…Yes / No Medication _________________________
you would like to resolve.
If yes specify_________________________
______________________________________________________________________
Vitamins____________________________
___________________________________
___________________________________
Supplements ________________________
___________________________________
2.Have you had any of these ___________________________________
___________________________________
health problems.
m Cancer
2. Do you exercise regularly?YES / NO
m Diabetes
If yes how often? ____________________2. When did this first occur and how?
m Epilepsy
What type? _________________________ ___________________________________
m Heart / respiratory
m Hormonal ___________________________________
m High / low B.P.
m Hysterectomy / varicose veins 3. Follow a restricted diet? YES / NO ___________________________________
m H.I.V / hepatitis if yes specify________________________
m Infectious skin disease ___________________________________
3.Have you sought other treatment,
m Spinal problems
if so how did your condition respond?
4.How much water do you consume ___________________________________
m Other please specify_______________
daily? ___________________________________
___________________________________
___________________________________
3.Have you / do you get allergies to Female clients only ___________________________________
m Medicine
m Pollen 1. Are you taking oral contraception?
m Animals YES / NO
4. On a scale of 1-10 what is your
m Food
2. Are you pregnant
Please specify________________________ YES / NO daily energy level?
___________________________________
3. Had miscarriage/ termination
YES / NO

4. Passed menopause YES / NO

* This form is an aid in clarification of the clients needs. Information is completely confidential.

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