Client Registration Form
Today’s Date: _____________
IDENTIFACTION
Name: _______________________________________ Date of birth: _____________ Age: ___
Spouse (if applicable): ____________________________ Date of birth: _____________ Age: ___
Address: _____________________________________________ Contact H/P: _______________
_____________________________________________ Home: _______________
Email address: ______________________________________________________
Sex: □ Male □ Female Nationality □ Malaysian □ Non-Malaysian Ethnicity: ____________
Height: __________ cm Weight: ____________ kg Religion: ____________
Handedness: □ Right □ Left Employment status: □ Full time □ Part time □ Retired
Marital status: □ Single □ Engaged □ Married □ Divorced
Mode of contact: □ Home # □ H/P □ WhatsApp □ Email
CHILDREN INFORMATION (IF APPLICABLE)
NAME AGE SEX OCCUPATION/GRADE LIVING WITH
FAMILY INFORMATION
Number of family members: ____________________
NAME AGE SEX RELATIONSHIP OCCUPATION LIVING
WITH
1
EMPLOYMENT HISTORY
Fill up this part even if you are working or had worked in part-time job
OCCUPATION COMPANY / YEARS OF REASONS FOR LEAVING
EMPLOYER WORKING
EDUCATION HISTORY
Please list down all formal education received.
NAME DURATION GRADE FEEDBACKS /
COMPLAINS
Kindergarten
Primary
Secondary
College/University
Further study
2
PRESENTING ISSUES
Please list down your concerns or reasons for the visit:
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Do you smoke or vape? □ Yes □ No
If yes, please specify the amount. _______________ box / stick per day (Circle whichever applicable)
Do you drink alcohol? □ Yes □ No
If yes, please specify the amount. _______________ glass per day / week ((Circle whichever applicable)
Do you use recreational drugs? □ Yes □ No
If yes, please specify the amount. _______________
3
CHILDHOOD AND DEVELOPMENTAL HISTORY
Pregnancy, delivery and birth
Were there any problems or complications during your mother’s pregnancy with you or at your birth?
If so, please describe.
Developmental history
Were there any problems during your development, such as delayed walking, talking, or problems
relating to others? If so, please describe:
PERSONAL MEDICAL HISTORY
PERSONAL AND FAMILY HEALTH HISTORY
List any medications currently prescribed to you, dosages and reason for the medication:
MEDICATIONS DOSAGE REASONS
4
Please list any diagnosed medical or psychological conditions.
MEDICAL OR PSYCHOLOGICAL CONDITIONS YEAR TREATMENT
Is there anyone in your extended family that was diagnosed with any medical disease or
psychological disorders? Please specify if they are from the mother’s or father’s extended family
ADDITIONAL INFORMATION
Please provide any other information or describe any other concerns that have not been
covered in this questionnaire.
5
EMERGENCY CONTACT
In case of emergency, please notify _______________________________ Contact: ________________
Relationship: __________________________________ Alternative contact: _____________________
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Signature - Client or Parent/Guardian For Office Use
Date:
Client ID:
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