Adult Health Assessment

New Client Form

Please complete this Wellness History Form and submit via email at least 3 days prior to your session. Should you have any questions, please note that in the Additional Comments section.

Full Name (required)

Street, City, State ZIP (required)

Email address (required)

Daytime Phone (required)

Evening Phone (required)

Referred by (or how did you find me) (required)

Date of Birth (required)

Emergency Contact Name & Phone (required)

New or Recurring Situation (required)

Is this a new or recurring issue?

Why Are You Coming To See Me? Describe the problem(s) for which you seek help and approximate dates when they first occurred. (required)

PAST MEDICAL HISTORY: Please list all past injuries, accidents, surgeries, illnesses with either approximate date of occurrence or age.

MEDICATION & SUPPLEMENTS: Please list any and all prescription or over-the-counter medications and/or any supplements that you're currently taking. (required)

YOUR CURRENT CHALLENGES: What daily activities are difficult for you?

YOUR GOALS: What are your goals for our work together?

OTHER HEALTHCARE PROVIDERS: Please list any medical practitioners who you are currently seeing for this/these problems.

MEDICAL PROCEDURES: Please list any medical procedures you've had over the last year and any surgeries since birth.

Past Trauma(s)

List with approximate date and/or age past trauma that you've experienced in your life to include emotional, physical, mental, spiritual etc.

Emotional Trauma: such as someone dying: animal or person, a divorce: yours or your parents, losing a job, not getting a promotion, the breakup of any close relationship - friend, family, or life partner, abuse

Physical Trauma: accident or illness: events such as concussions, falling off a swing when young and hitting your tailbone, definitely include all surgeries and broken bones. Also include illness of close friends, family, animal companions, addictions in the family, etc.

Mental Trauma: Overwhelmed with too many bases to cover, financial trauma, a lot of criticism or judgement in childhood, alcohol, drug, gambling addiction in the family causing children to have too much responsibility too soon.

Spiritual: loss of faith, why me?

How many hours a night do you sleep?

Is your sleep restful?

Yes

Sometimes

WHERE DOES IT HURT? If you have physical discomfort, please share where your aches and pains are. List each area and indicate the severity of the pain with 1 being slight and 10 being very severe.

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