Medical History Form

Confidential Client Questionnaire	Family name
Confidential Client Questionnaire	First Name
Date	Address
Date of birth
Occupation
How did you find out about me?

	Phone, Daytime
Doctor’s name	Phone, Evening
Practice name	Mobile

Family situation	Single? Living alone? Living with parents? Living with partner? Married? Separated? Other?
If a child, parent’s names
Spouse/ partner’s first name
Children: names & ages

Weight	Height
Are you happy with your weight?	If not, what is your ideal weight?

What other treatments are you having / have tried?

Medical history

Any past surgery, serious illness, accidents/injuries with approximate dates

What was your health like as a child?

Was there anything abnormal about your birth?

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What areas, problems or goals would you most like help with now?

List any emotional traumas/ episodes, with approximate dates, as far back as you like. (eg. bereavements, divorce, parents split-up etc.)

Any relationship problems including friends, family, work, etc.

Describe a typical day’s eating & drinking:

Breakfast

Lunch

Evening meal

Between meals

What do you do for exercise and relaxation?

Any current drugs & what for?

Any medication taken in the past, especially if for a long period

Have you reacted to any medication? Y/N What & how?

Do you smoke? Y/N If so, what & how many a day?

Do you drink alcohol? Y/N If so, what & how often?

Do you use recreational drugs? Y/N If so what & how often?

If not now, have you in the past? Y/N If so what?

(tick + any comment such as for how long)

I have had, but not now (tick + any comment such as when)