Personal Data – Session Form
City, State, Zip
How were you referred?
Friend (Name)____________________ Ad__________Pathways Magazine_________ Yelp ________Doctor (Name) ________ Others______________
Date you would like appointment
Date of Birth
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?
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
Abscess or open sore
Skin sensitivity Allergies
Herpes I or II
Other infectious diseases
Rheumatoid arthritis Fibrositis
Chronic Fatigue Syndrome Herniated disc
Inner ear problem Pregnancy/Now Intrauterine Device
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.
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.