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Client Questionnaire and Case History
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Confidential
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| Name : |
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| Date : |
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| Birth Certificate Name : |
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| Phone: |
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| Address : |
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| Postcode : |
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| Telephone No. Day : |
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| Evening : |
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| Mobile : |
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| Email : |
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| Date of Birth : |
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| Age Now : |
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| 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)
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Do you recall any emotional traumas? Please list.
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Do you have any allergies?
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Do you have any addictions/cravings?
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Describe your present home and family environment.
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Describe your main occupation. Are you happy in it?
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Describe your diet.
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Describe your level of activity and exercise.
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Do you feel your sexuality is flowing or is blocked in any way. Now or in the past?
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Menstrual Cycle (e.g. Regular, irregular, PMS).
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Do you meditate or have a spiritual practice?
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Describe the alternative therapies you have already received.
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| 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. |
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