Client Diagnostic Form

Client Diagnostic Form
Name

First NameLast Name
Date

DayMonthYear
Date
BODY - PHYSICAL
Do you suffer from any chronic physical pain? Please give details.
Are you undergoing any treatment? If yes, please give details.
Do you suffer from any pain or disorders relating to the following:

MusclesBonesSkinDigestive systemHemorrhoidsTeethHeadaches/MigrainesAddictionVisionArthritis/Joint painInfections/VirusAsthmaBood disorderEating disorder
Other, please give details.
Have you had any major operations? If yes, please give details and dates.
Appetite
How is your appetite?
Would you consider yourself to be an emotional eater?
Which part of your body gathers most fat?
MIND - EMOTIONAL
How you would describe your current emotional state?
If you are experiencing any emotional issues currently, how long has this been going on?
Does anything trigger your feelings in particular?
Is there anything that helps you to feel better?
THERAPIST NOTES
Should be Empty:

BODY - PHYSICAL