Client History Questionnaire
Please complete this form with as much detail as you need to. When seeing any practitioner, myself or another, your best course, as a client, is to tell us everything, and allow us to sift through the data for important points. Things that may feel incidental to you may actually be critical clues to us. Be factual! If you drink six cups of coffee a day, don't tell us that you only have two. We are not judging, but we are employed, by you, the client, to figure out what is happening and effecting your health, and without accurate information, we are not going to be effective.
Email address *
Who referred you to us?
or how did you find us?
Your answer
Your Identity
This information is needed for accurate records of a medical or therapeutic nature under health care regulations in Australia.
Your full name *
Please use your full name as it appears on your passport or driver's license, not a nickname. Example; Robert instead of Bob, or Catherine instead of Kate.
Your answer
Preferred name
Do you prefer a different name? Example; your name is Robert but you prefer Rob or Bob.
Your answer
Date of birth *
Needed for record keeping.
MM
/
DD
/
YYYY
Your residential address *
Please write your address, in the appropriate format, that would see mail accurately delivered to your home address.
Your answer
Your postal address *
Please write your address, in the appropriate format, that would see mail accurately delivered to your preferred postal address. If it is the same as your residential address, please just write "As Above".
Your answer
Your primary phone number *
Mobile (cellular) preferred, or a number able to receive text messages.
Your answer
Alternate contact numbers
One number per line, in order of preference, please.
Your answer
For which service are you completing this form? *
If you are seeing Craig for more than one service, please return and complete this section again. You will be taken to a different section, depending on your response. For example, if seeking myotherapy for pain, and wanting help with a phobia, these are two very different things. Each requires different historical information that is not needed for the other.
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