Client History Form Step 1 of 2 - Step 1 50% Date* Name* First Last Date of Birth* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Phone*Alternate PhoneEmail* How did you hear about our office?Personal HistoryHave you received prior treatment for your problem?* Yes No Please explain the treatment received, and by whom*What techniques/ methods were used?*How long have you received treatments?*And at what frequency?*Has treatment been discontinued?* Yes No Why?*Please give a brief description of what you would like to accomplish from your sessions:*General Physical TraumaWere you ever knocked unconscious?* Yes No Have you ever broken any bones?* Yes No Have you everhad any impacts, falls, or jolts that you feel specifically have injured your spine?* Yes No Please explain*Have you had extensive dental work?* Yes No Have you had Orthodontia?* Yes No If appropriate, procide additional explanation of symptoms on the preceding sectionPlease list any physical symptoms or issues that you currently have or have had in the past, that were not mentioned in the preceding sectionHow do you grade your physical health?*ExcellentGoodFairPoorGetting BetterGetting WorseHow is your physical health affecting your daily lifestlye and personal interactions?Are you currently taking any prescription drugs?* Yes No Please list the prescription drugs you are currently taking*AccidentsHave you ever been involved in a vehicular collision?* Yes No Please list approximate dates and severity* Food and DietPlease review each food and diet item and choose the selection that best fits how often you consume. Alcohol*DailyA few times a weekWeeklyMonthlyNeverArtificial Sweetener*DailyA few times a weekWeeklyMonthlyNeverBeef*DailyA few times a weekWeeklyMonthlyNeverCoffee*DailyA few times a weekWeeklyMonthlyNeverCooked or Canned Vegetables*DailyA few times a weekWeeklyMonthlyNeverDairy Products*DailyA few times a weekWeeklyMonthlyNeverDiet Food*DailyA few times a weekWeeklyMonthlyNeverEggs*DailyA few times a weekWeeklyMonthlyNeverFasting*DailyA few times a weekWeeklyMonthlyNeverFish*DailyA few times a weekWeeklyMonthlyNeverFried Foods*DailyA few times a weekWeeklyMonthlyNeverFruit*DailyA few times a weekWeeklyMonthlyNeverOrganic Foods*DailyA few times a weekWeeklyMonthlyNeverPoultry*DailyA few times a weekWeeklyMonthlyNeverRaw Vegatables*DailyA few times a weekWeeklyMonthlyNeverRefined Sugar*DailyA few times a weekWeeklyMonthlyNeverSeafood*DailyA few times a weekWeeklyMonthlyNeverSoda*DailyA few times a weekWeeklyMonthlyNeverTobacco*DailyA few times a weekWeeklyMonthlyNeverWeight Control Diet*DailyA few times a weekWeeklyMonthlyNeverWhole Grains*DailyA few times a weekWeeklyMonthlyNeverThe type of diet I usually follow is classified as:*Are you currently taking any daily supplements?* Yes No Please list your daily supplements:*Emotional StatusHow do you grade you emotional/ mental health?*ExcellentGoodFairPoorGetting BetterGetting WorseHow does your emotional/ mental health affect your daily lifestyle and personal interactions?*Childhood - Present*MildModerateExtremeChildhood - Past*MildModerateExtremeSchool Stress - Present*MildModerateExtremeSchool Stress - Past*MildModerateExtremePlay or Recreational Stress - Present*MildModerateExtremePlay or Recreational Stress - Past*MildModerateExtremeFamily Stress - Present*MildModerateExtremeFamily Stress - Past*MildModerateExtremeWork Related Stress - Present*MildModerateExtremeWork Related Stress - Past*MildModerateExtremeStress of Commuting - Present*MildModerateExtremeStress of Commuting - Past*MildModerateExtremeLoss of a loved one - Present*MildModerateExtremeLoss of a loved one - Past*MildModerateExtremeChange in Lifestyle - Present*MildModerateExtremeChange in Lifestyle - Past*MildModerateExtremeChange in Vocation - Present*MildModerateExtremeChange in Vocation - Past*MildModerateExtremeAbuse - Present*MildModerateExtremeAbuse - Past*MildModerateExtremeAnxiety - Present*MildModerateExtremeAnxiety - Past*MildModerateExtremeDespression - Present*MildModerateExtremeDespression - Past*MildModerateExtremeLoss of Balance - Present*MildModerateExtremeLoss of Balance - Past*MildModerateExtremeScattered Thinking - Present*MildModerateExtremeScattered Thinking - Past*MildModerateExtremeFatigue - Present*MildModerateExtremeFatigue - Past*MildModerateExtremeInsomnia (trouble getting to sleep) - Present*MildModerateExtremeInsomnia (trouble getting to sleep) - Past*MildModerateExtremeInsomnia (walking in the middle of the night) - Present*MildModerateExtremeInsomnia (walking in the middle of the night) - Past*MildModerateExtremeOversleeping - Present*MildModerateExtremeOversleeping - Past*MildModerateExtremeNervousness - Present*MildModerateExtremeNervousness - Past*MildModerateExtremeRepressed Anger - Present*MildModerateExtremeRepressed Anger - Past*MildModerateExtremePainful Experiences - Present*MildModerateExtremePainful Experiences - Past*MildModerateExtremeAbandonment Issues - Present*MildModerateExtremeAbandonment Issues - Past*MildModerateExtremeIf appropriate, provide additional explanation of symptoms noted on previous page:Please list any other emotional symptoms or issues that were not mentioned on the preceding pages that you now have or have had in the past:Birth HistoryWas your delivery:Drug induced"C" sectionBreechProlongedForceps or suctionCord around neckOtherDescription of Other:*MedicalHave you ever been hopitalized?* Yes No Why were you hospitalized?*Have you ever had surgery?* Yes No What type of surgery and why?*Do you still have all of your body parts/ organs?* Yes No Do you wear glasses, bifocals, or contact lenses?* Yes No Which do you wear?*Thank you for taking the time to complete this client history form.