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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