Adult-Client Information Package

First Name:

Last Name:

Today's Date:

Date

Phone Number (### ###-####)

Area CodePhone Number

Type a phone

DOB:

Age:

Number and Street

City

State

Zip Code

Email:

example@example.com

Additional Contact:

Name

Relationship

Area CodePhone Number

Email: example@example.com

Additional Contact:

Name

Relationship

Area CodePhone Number

Email: example@example.com

Additional Contact:

Name

Relationship

Area CodePhone Number

Email: example@example.com

If we call you, may we leave a message with someone else?

May we leave a voicemail message?

May we send appointment reminders?

Goals for training or primary problem(s) you'd like to improve:

Other providers helping with these issues (please provide contact details)

HOW DID YOU HEAR ABOUT US?

*IF MEDICAL OR MENTAL HEALTH PROFESSIONAL, PLEASE PROVIDE NAME, CITY, STATE

List all prescribed medications/how long on them?/comments

List all supplements/OTC medications/how long on them?/comments

First Name:

Last Name:

Today's Date:

Date

What brings you here today?

Handedness:

Which of these have you experienced?

Explain:

What time do you typically fall asleep?

How long to fall asleep? (minutes/hours)

Wake up easily?

Client Name:

Typically sleep through the night, except for getting up to go to the bathroom?

Wake feeling rested?

Comments about your sleep:

Are you sensitive to caffeine? (Coffee, Tea, Chocolate, Cola)

Does caffeine make you...

Do you use alcohol?

Does alcohol make you:

Do you have a history of using recreational drugs?

If yes, explain

Do you have any psychiatric or mental health diagoses?

If yes, explain:

Have you had any hospitalizations related to psychiatric or mental heal issue?

If yes, explain:

Have you had any suicidal thoughts or thoughts of self-harm?

Have you had any suicidal plans or plans of self-harm?

Have you had any suicide attempts or attempts of self-harm?

If you had any suicidal thoughts, plans or attempts, explain:

First Name:

Last Name:

Provide any important family history issues that may relate to current challenges/symptoms (divorce, disruptions in family, major job challenges, loss of family or friend, etc.)

History of help utilized:

Comments regarding the help you have used:

How long have you been dealing with your primary issues?

How often do these issues occur?

What, if anything has helped these issues in the past?

How much do your issues hinder your ability to engage in activities or work or be with family or friends?

Which, if any, of the following physical symptoms do you sometimes exprience? (check all that apply)

Do you have any history of trauma/being bullied/being physically or emotionally abused?Type a question

If yes, please explain:

Do you sometimes have problems keeping up/being sharp/making decisions?

If yes, please explain:

Check any of these which apply:

How would you describe yourself?

Do you have excessive sensitivity to light/sound/noise?

This is a "Gut Brain question": Estimate how many rounds of antibiotics you've had since you were born:

Adult Client Information

Sleep Patterns:

Adult History