Personal Data  – Session Form

Name

Address

City, State, Zip
Email

How were you referred?

Friend (Name)____________________ Ad__________Pathways Magazine_________ Yelp ________Doctor (Name) ________ Others______________

Phone

Date  you would like appointment

Date of Birth
Occupation(s)

Interest(s)

What is your previous experience with professional Consultation / Coaching?

What is your goal/concern for today’s session?

 Is there any area where you would like extra time spent, or any area where you seem to hold a lot of tension?

 

Lifestyle:

Nutrition

Exercise

Tobacco

Alcohol

How are your Bowels_

Drugs (non-med.) Caffeine

Posture assumed most of day

How well do you Sleep
Recreation / Hobbies

Are there specific aspects of your life that are particularly stressful (job, posture, habits, diet, family, etc.)? Explain.

Medical History: (give dates) Hypertension

Heart disease Arteriosclerosis Varicose veins Phlebitis

Fluid retention Epilepsy Headaches Cancer/malignancy Diabetes

PMS/painful menstruation Easy bruising
Skin rash
Abscess or open sore

Skin sensitivity Allergies
Herpes I or II
HIV positive
Other infectious diseases

Mental illness

Osteoporosis Osteoarthritis
Rheumatoid arthritis Fibrositis
Fibromyalgia
Chronic Fatigue Syndrome Herniated disc

Inner ear problem Pregnancy/Now Intrauterine Device

Fractures
Are you taking any medications? If so, what and what for?

Medical History: (Continued) Surgery/fractures (explain) (dates):

Implants of any kind:
Prior injuries (explain) (dates):
Musculoskeletal pain/stiffness (such as low back, neck, shoulder, etc. (explain) (dates): Any other physical or health difficulties?
Any difficulty lying on your back, front, or turning?

To better develop a session that meets your individual needs, it will be helpful to know if you have:

Any counseling history:
Any history of abuse (recent or past verbal, physical, sexual, or emotional):
Any recent lifestyle/emotional challenge or loss:
Are you under the care of a physician or other medical practitioner now? ( ) A counselor?

For what conditions?
Do we have your permission to contact your physician should the need arise?

Name of physician Phone

This information will be treated confidentially. In order to maximize the effectiveness and safety of our sessions together, please give your feedback during and at the end of the sessions. This will help in tailoring the session to serve you in the best possible way.

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I have read the above information and discussed it with my practitioner. I understand that this work does not constitute medical treatment. It is a form of health and wellness maintenance. I take responsibility for alerting my practitioner to any physical  of mental conditions that would affect this work.

Signature Date