CLIENT INFORMATION FORM

 

CLIENT'S NAME_____________________________________________________________

ADDRESS_________________________________________________________________

                 _________________________________________________________________

CITY _________________________________ STATE___________ ZIP________________

PHONE # _________________________ ALTERNATE PHONE # _____________________

GENDER (circle one)       M / F            AGE _______

PLEASE CIRCLE ONE : Single   Married   Divorced   Separated   Widow(er)  Living w/ partner

EMPLOYER ______________________ OCCUPATION: ____________________________

 

EMERGENCY CONTACT INFORMATION:

 

NAME _____________________________________________________

PHONE # ___________________________________________________

ADDRESS _________________________________________________

RELATIONSHIP TO CLIENT ____________________________________

 

Are you currently under the care of a physician?     YES            NO

 

DAILY PHYSICAL ACTIVITY LEVEL (As required by your lifestyle and/or job) circle one    

 inactive      1                      2                            3                         4                            5    active

Do you exercise regularly?            YES                NO           If yes, please describe the type of exercise, length of workout, and frequency. _________________________________________________________________________

 

Have you ever been diagnosed with a mental disorder?     YES               NO

If yes, please indicate the type of treatment you are receiving. ________________________

__________________________________________________________________________

Are you on a diet of any kind?         YES                NO

If yes, please describe the diet _________________________________________________

__________________________________________________________________________

 

MEDICAL HISTORY

Do you have a history of any of the following?

 

 

YES

NO

 

YES

NO

ALCOHOL / DRUG DEPENDENCY

 

 

HEART PROBLEMS

 

 

ALLERGIES

 

 

HEPATITIS TYPE ___

 

 

ANEMIA

 

 

HERNIA

 

 

ARTHRITIS

 

 

HIGH / LOW BLOOD PRESSURE

 

 

ASTHMA

 

 

HIV / AIDS

 

 

AUTOIMMUNE DISEASE

 

 

HYPER / HYPO THYROIDISM

 

 

BACK PROBLEMS

 

 

JOINT PROBLEMS

 

 

BLOOD IN STOOL

 

 

KIDNEY PROBLEMS

 

 

BLOOD IN URINE

 

 

SURGERY (within last 3 years)

 

 

BLURRED VISION

 

 

MALARIA

 

 

BRONCHITIS

 

 

MONONUCLEOSIS

 

 

CANCER

 

 

NAUSEA / VOMITING

 

 

DIABETES

 

 

NUMBNESS IN LIMBS

 

 

DIZZINESS / FAINTING

 

 

RESPIRATORY PROBLEMS

 

 

EPILEPSY

 

 

RHEUMATIC FEVER

 

 

EYE PROBLEMS

 

 

STOMACH PROBLEMS

 

 

GENETIC DISEASE

 

 

TUBERCULOSIS

 

 

HEADACHES

 

 

ULCERS

 

 

HEARING PROBLEMS

 

 

OTHER NOT LISTED

 

 

 

Are you allergic to any medications?     YES           NO

If yes, please specify: ___________________________________________________________

 

Please list all medications, vitamins, herbs, & supplements you are currently taking.

 

   
   
   
   
   
   
   

 

I hereby certify that the information provided above is accurate and complete to the best of my knowledge.

 

 

 

SIGNED___________________________________________     DATE_________________