Client Chart Therapist:________________________

Name Date: Fax:
Address City Email
Home Phone Postal Code
Occupation Employer
D.O.B. Family Doctor
Referred by Reason for Appointment
Are you under medical treatment now?

List current medications, herbs & supplements List allergies: Drugs, Plants or other

Please check any of the symptoms or physical problems listed below that you experience:

Allergies Diabetes Epilepsy Arthritis Scoliosis
Headaches Asthma Dizziness Weakness Indigestion
Sciatic High/Low BP Hearing Insomnia Vision
Cardiovascular Vascular Memory Fatigue Numbness
Back Pain Reproductive Sleep Sinus Migraines
Alcohol Chronic Fatigue Candida Ulcers Hepatitis
Cancer Thrombosis Bronchitis Warts Fungal Infections

Are you currently pregnant or trying? Have you been tested for HIV? Positive ?

Do you have any skin conditions? Have you had a recent injury?

Are you in severe pain at this time? Have you taken pain medication today?

Current Health Poor Good Excellent
Current Stress Level: Low Moderate High

DISCLAIMER: As a professional therapist, I do not make any claim of replacing any holistic or medical therapy. This therapy is of a complimentary nature only, rather than a curative treatment in itself. I adhere to the standards of practice and code of ethics set out by our respective governing bodies. I accept the responsibility of knowing what treatment that I want and have agreed to with this therapist.

Client's Signature of Consent for Treatment: ________________________________________________