Adult Health Assessment

As a new client, I am thankful that you’re here and I sincerely look forward to working with you. A chunk of time during your first session will be spent discussing your life and family history and it will save a lot of time if you can complete the history assessment prior to your session. Simply fill out the form below. It should take about 10 – 20 minutes and would be easier to complete on a computer as opposed to a mobile device.

PLEASE NOTE: This form is to be completed ONLY after you’ve spoken with me and/or I’ve asked you to please fill this out. 

Email *
Full Name  *
Street, City, State ZIP
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Email Address  *
Daytime Phone
Evening Phone *
Referred by (or how did you find me)  *
Date of Birth
MM
/
DD
/
YYYY
Emergency Contact Name & Phone *
Emergency Contact Name
Emergency Contact Phone
New or Recurring Situation
Why Are You Coming To See Me? Describe the problem(s) for which you seek help and approximate dates when they first occurred. 

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PAST MEDICAL HISTORY: Please list all past injuries, accidents, surgeries, illnesses with either approximate date of occurrence or age.

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MEDICATION & SUPPLEMENTS: Please list any and all prescription or over-the-counter medications and/or any supplements that you're currently taking. 

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YOUR CURRENT CHALLENGES: What daily activities are difficult for you?

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YOUR GOALS: What are your goals for our work together?

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OTHER HEALTHCARE PROVIDERS: Please list any medical practitioners who you are currently seeing for this/these problems.

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MEDICAL PROCEDURES: Please list any medical procedures you've had over the last year and any surgeries since birth.

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Past Trauma(s)

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Past Trauma(s)

List with approximate date and/or age past trauma that you've experienced in your life to include emotional, physical, mental, spiritual etc.

Emotional Trauma: such as someone dying: animal or person, a divorce: yours or your parents, losing a job, not getting a promotion, the breakup of any close relationship - friend, family, or life partner, abuse

Physical Trauma: accident or illness: events such as concussions, falling off a swing when young and hitting your tailbone, definitely include all surgeries and broken bones. Also include illness of close friends, family, animal companions, addictions in the family, etc.

Mental Trauma: Overwhelmed with too many bases to cover, financial trauma, a lot of criticism or judgement in childhood, alcohol, drug, gambling addiction in the family causing children to have too much responsibility too soon.

Spiritual: loss of faith, why me? *
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