Client information sheet

Name

Date of Birth

Address

Phone number/s

Email

Marital status Marital status Single Married Living with partner Separated Divorced Other

Do you have any children? Do you have any children? Yes No

How many children?

What age range? What age range? 0-1 1-4 5-11 12-18 19+

Hobbies & recreation?

Who were you referred by

GP name and address

Permission to contact GP Permission to contact GP Yes No

Describe the health problems you’re experiencing

How severe do you consider your health condition to be? How severe do you consider your health condition to be? Severe Moderate Mild

Do/have you used other forms of therapy?

How successful were they? How successful were they? Excellent response Moderate improvement Made no difference Aggravated problems

List previous illnesses/accidents or surgery

Please list any medication you are using:

In what way do you expect your problems to improve?

How long do you expect total recovery to occur?

Are you currently taking supplements (vitamins etc)?

What is your consumption of water per day? (Not including fruit juice, soft drinks, herbal teas, tea & coffee) What is your consumption of water per day? (Not including fruit juice, soft drinks, herbal teas, tea & coffee) 2 litres + 2 litres 1 litre 500ml Less

Briefly describe your diet:

What are your favourite foods?

What are your bowel movements? What are your bowel movements? More than twice per day Twice per day Once per day Less than once per day

How often do you exercise? How often do you exercise? Every day 2 - 3 times per week Once a week Less than once a week

On a scale of 1 - 10 what are your energy levels

Where do you want it to be?

Do you sleep well, if not, why?

Do you smoke? Do you smoke? No Yes (social) Yes: 1- 10 per day Yes: 11- 20 per day Yes: more that 20 per day

Do you use orthotic appliances in your shoes? Do you use orthotic appliances in your shoes? Yes Sometimes No

Do you experience pain and if so, where?

On a scale of 1 - 10 what is your pain level

Do you experience: ringing in the ears / clicking/popping of the jaw / facial pain?

Have you had your wisdom teeth out? was it all at once?

Other teeth removed; was it for overcrowding?

Is there any chance you could be pregnant?

Your menstrual cycle is: Your menstrual cycle is: Regular Irregular Painful Heavy Menopausal Other

Do you have breast or other implants?

Add any other concerns/comments about treatment

I declare that the information that I have given is correct and as far as I am aware I can undertake the treatment without any adverse effects. I have been fully informed about the contract-indications and I am therefore willing to proceed with the treatment. I declare that the information that I have given is correct and as far as I am aware I can undertake the treatment without any adverse effects. I have been fully informed about the contract-indications and I am therefore willing to proceed with the treatment. Yes No