Checklist of Client Concerns

Checklist of Client Concerns

Below is a list of problems that clients frequently describe to us. Please check off any that match your current concerns. If you are not sure whether to endorse an item, use the past week as a guide. Feel free to add any comments as necessary.
Client Name:

First NameLast Name
Date:

MonthDayYear
Date
Email:
example@example.com
Pre/Ongoing/Post Date:
Immune System:

AllergiesAsthmaFrequent colds, infectionsYeast infectionsFatigue
Sleep:

Difficulty falling asleepWakeful or restless during nightWaking up earlyDifficulty waking upNightmares or night terrorsSnoringSleep walking
Skin / Hair / Nails:

Problems with skinHairNails
Eyes:

Double or blurred visionBlind spotsSpots in your vision
Ear / Nose / Throat:

Hearing lossRinging in earsEarachesSense of smell changed or lostNose or sinuses blockedGrinding your teethSense of taste changed or lostHoarseness or sore throat
Heart / Lungs:

Problems breathingHeart problemsHypertensionPalpitationsDizziness
Intestines:

Nausea or vomittingGastric painGas or bloatingIrritable bowelDiarrheaConstipation
Hormonal / Blood:

Appetite problems (e.g. wanting to eat when not hungry)DiabetesDesire for sweets or carbohydratesSensitivity to heat or coldThyroid problemsPMS symptomsHot flashesOther menopausal symptomsLow interest in sexExcessive interest in sex
Bones / Joints / Muscles:

Pain or stiffness in joints or musclesSore trigger pointsFibromyalgiaBodily fatigue
Nervous System:

Headaches or migrainesFaintingSeizuresMemory lossBlocking on wordsReading problemsDifficulty speakingTremor (shaking)WeaknessHyperactivityProblems with balanceMotor or vocal tics
Attention and Organization:

Difficulty focusingEasily distractedMake mistakesDifficulty organizing activitiesNot completing tasksLose train of thought
School / Learning:

Difficulty completing schoolworkGetting into trouble at schoolInverting letters/numbersDifficulty with particular subjectsSpatial problems (e.g. difficulty building things, understanding how things should be put together)
Bowel / Bladder:

Difficulty urinatingDifficulty holding your urineDifficulty controlling your bowelsFrequent bladder infections
Habits:

Sometimes drink too muchSmoke cigarettesConcerns about your dietDesire caffeineUse marijuanaOther addictions
Behavior / Emotions:

Mood swingsFeeling down, depressed or flatFeeling sadFeeling anxiousPanic attacksWorryThoughts that won't leave your mindNeed to repeat actions or words over and overBingeingRestricting your food intakeMaking yourself vomitPhobias - avoiding thingsFeeling others are against youBehaviors that get you into trouble, or are not good for youFeeling angry a lotImpulsiveFeeling overwhelmed
Concerns not listed:
Should be Empty: