Client Questionnaire


 

Client Questionnaire and Case History
Confidential
Name :
Date :
Birth Certificate Name :
Phone:
Address :
Postcode :
Telephone No. Day :
Evening :
Mobile :
Email :
Date of Birth :
Age Now :
Computer Type : Please tick   PC   Mac  Microsoft Excel
Medical History – any operations, accidents, illnesses, medication.
Present health and medication.
Describe relationship with Mother – whilst growing up & how it is now.
Mother’s Birth Certificate name and Date of Birth
Describe relationship with Father – whilst growing up & how it is now.
Father’s Birth Certificate name and Date of Birth
Your Birth and Time in the Womb (e.g. premature, method of delivery etc.)
Have you ever taken recreational drugs? (if yes, list them all)
Have you ever abused alcohol?
Smoking :   Yes   No
Have you had any major dental work?(Please detail)
Do you recall any emotional traumas? Please list.
Do you have any allergies?
Do you have any addictions/cravings?
Describe your present home and family environment.
Describe your main occupation. Are you happy in it?
Describe your diet.
Describe your level of activity and exercise.
Do you feel your sexuality is flowing or is blocked in any way. Now or in the past?
Menstrual Cycle (e.g. Regular, irregular, PMS).
Do you meditate or have a spiritual practice?
Describe the alternative therapies you have already received.
Please list in order of priority what you feel you most need help with.
  I understand that healing is not a medical treatment. I also appreciate that it is my responsibility to seek medical care for any problem or illness.