New Client Medical History Form

1
New Client Questionnaire

The purpose of this questionnaire is to obtain a comprehensive picture of your background. By completing these questions, as fully and as accurately as you can, you will provide your therapist with important information, without using your actual therapy time. Please answer these questions on your own time. The information in this questionnaire will be kept by your therapist and will not be disclosed to anyone without your written permission. Case records are strictly confidential.

You may choose to skip answering any question you feel impinges on personal information you do not wish to disclose other than the fields marked with an asterisk *.
2
Full Name* This field is required.
First Name
Middle Name
Last Name
3
Address* This field is required.
Street Address
Street Address Line 2
City
State
Post Code
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
4
Birth Date* This field is required.
Day
Month
Year
5
E-mail* This field is required.
6
Mobile Phone Number* This field is required.
7
How did you hear about us?* This field is required.
Please Select
Please Select
Google
Referred
Facebook
Health practitioner
Internet
HMI
Other
8
If you were referred, who can we thank for referring you?
Full name please
9
Emergency Contact* This field is required.
Name & contact number
10
Have you ever had Hypnotherapy before?
Please Select
Please Select
Yes
No
11
Was the treatment effective?
12
State in your own words the nature of your main problems and their duration. * This field is required.
13
Please estimate the severity of the issues.
Please Select
Please Select
Mildly Upsetting
Moderately Severe
Very Severe
Extremely Severe
Totally Incapacitating
14
With whom have you previously consulted about your present problem(s)?
15
Please select any of the following words that apply to you.
worthless
useless
nobody
life is empty
inadequate
stupid
incompetent
naive
can't do anything right
guilty
evil
morally wrong
horrible thoughts
hostile
full of hate
anxious
agitated
cowardly
unassertive
panicky
aggressive
ugly
deformed
unattractive
depressed
unloved
misunderstood
bored
restless
confuses
unconfident
in conflict
full of regrets
worthwhile
sympathetic
intelligent
attractive
confident
considerate
assertive
16
What are your fears?
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Ok
17
Choose any of the following that apply to you.
headaches
financial problems
fainting
palpitations
dizziness
loss of appetite
bowel disturbances
stomach trouble
insomnia
nightmares
fatigue
alcoholism
feeling tense
taking recreational drugs
taking prescription drugs
don't like weekends
sexual problems
can't make decisions
don't like vacations
can't make friends
overly rambunctious
can't keep a job
disoriented
unable to have a good time
concentration difficulties
memory problems
anxiety
want to quit smoking
18
What sort of work are you doing now?
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19
Does your present work satisfy you? If not, in what ways are you dissatisfied?
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20
What are your past and present ambitions?
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21
What are your present interests, hobbies and activities?
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22
What is the last grade of school you completed?
23
What are/were your scholastic abilities; strengths and weaknesses?
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24
Were you every bullied, severely bullied or severely teased?
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25
Do you make friends easily? If so, do you keep them?
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26
Who presently lives with you?
27
How many children do you have?
28
Do any of your children present special problems?
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29
Marital Status
Single
Engaged
Married
Divorced
Separated
Widowed
30
If married, how many times?
31
Is your father living or deceased? If deceased, what was your age at the time of his death? If alive, what is his present age, occupation and health?
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32
Is your mother living or deceased? If deceased, what was your age at the time of her death? If alive, what is her present age, occupation and health?
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33
In what areas of your family is there compatibility / incompatibility?
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34
As a child in what ways were you punished by your parents?
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35
Give an impression of your home atmosphere (i.e., the home in which you grew up). Mention the sate of compatibility between parents and between parents and children.
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36
What were your caregivers attitudes about sex (i.e., was there sex instruction or discussion in the home)?
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37
When and how old were you when you derived your first knowledge of sex?
38
Have you ever experienced any anxiety or guilt feelings arising out of sex or masturbation? If "yes", please explain.
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39
Were you able to confide in your parents?
40
If you have a stepparent, what was your age when your parent remarried?
41
If you were not raised by your parents, who raised you, and between what years?
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42
How do you get along with your in-laws? (This includes brothers/sisters in-law)
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43
Has anyone (parents, relatives, friends) ever interfered in your marriage, occupation, etc.?
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44
Who are the most important people in your life?
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45
Give a description of your religious training.
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46
Please complete the following:I am... I feel... I think... I wish...
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47
We promise not to bombard you with spam mail :) Would you like to receive our newsletter emails?* This field is required.
Yes
No
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