HI / PC / HC ..
Balanced Living
Client Adult History Sheet - Date:__________
Client Name D.O.B M / F
Address: . Place ..Postcode
Email: Preferred Mailing list: Mail / Email
Phone: . Mobile Phone: .
Partner: .M/F Married/ Living together/ Living separately
Siblings: Brothers . Sisters Your place in the family: .
Children:
Name |
Yr of Birth |
Name |
Yr of Birth |
|
M/F |
|
M/F |
|
M/F |
|
M/F |
|
M/F |
|
M/F |
Occupation: Interests/ Sports:
Health professionals you are consulting .
Food preferences: meat + 3 vegies / Vegetarian / Vegan/ High protein/ wheat gluten diary free.
Daily intake: Sugar: . Coffee: . Tea . Alcohol: . Water: ..
Smoking: .. Other:
Allergies: ..
Current Medication: ..
Current Supplements:
History:
Pre-Birth: Mother had: Nothing that I am aware off / Morning Sickness / Excessive Stress / Accidents/
other ..
Birth: Nothing that I am aware off/ Breech / Cesarean/ Forceps/ Other
0-2 year Development: Nothing that I am aware off / Developmental issues re; rolling crawling
sitting standing walking other: .
Childhood and other illnesses (include date or age):
..
Past Surgery: .
Shock, Trauma or Major changes (e.g. accidents, emigration, divorce, moving etc.)
..
More: ..
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