Healing Space - Client Information
Confidential
Name: ...... …...... ……......
If client is under 18 – Parental / Guardian’s name: ...... …...... ……...... …...... …......
Date of Birth: ...... Age: ...... … Marital Status: ...... … Children? Yes / No # age/s ...…...……...... …
Occupation: ...... ………………………………...………….. Referred By: ......
Address: ...... …...... …...... …….
...... …...... ……. Postcode: …………………………………..
Telephone (H): ...... Telephone (W) ...... ……..,...... Mobile: ....……...... …......
Email: ...... … Private Health Fund: Yes / No If Yes, which one: ...... …...... …
Purpose and Goals for treatment: ...... ………...... …...... ……...... …
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Presenting problem or condition: Please describe your symptoms:
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History of the problem: How past health links to the present symptoms. Include family related health conditions:
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Health Practitioners: Who is your medical doctor/clinic? Complementary therapists? Include the date last consulted.
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Recent Treatments: Any tests / treatments and results?
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Current Medication: Are you taking any medications or supplements? Please list, including when started and if any side effects.
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General Health(Past and Present) Please comment on any/all of these as appropriate.
Illnesses – Disorders, Accidents, Hospital, Operations: ...... …...... …...... ….
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Emotional or Mental Trauma: ...... ………………………………...... …...... …
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PastMedications (including vaccinations) and any side effects: ...... …...... …...... ….….
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Overseas Travel: Countries visited/when: ………………………………………………………………….……………………………………….
Rate 1-10, 10 being high or excellent: How do you rate:
Your present level of health? ………….. Your present level of energy or vitality? …………..
Your present stress levels? ………….. Your contentment? …………..
Your commitment to improving your health? ………….. Your outlook on your life? …………..
How confident are you in making suggested dietary, lifestyle and exercise modifications to improve your health and wellbeing? ……...…
Are you willing to make changes to your diet and lifestyle to improve your health? Yes No Maybe
What do you think could stop you from achieving your health goals?
Time Interest Support Money Commitment Health Transport Other
Describe: ………………………………………………………………………………………………………….………………………………………
Life Style Factors:Please comment on any/all of these as appropriate.
Diet: Do you eat a specific diet? Yes / No Describe: ...... …..………...... …......
Food Preferences, Cravings, Allergies, Sensitivities: ...... …...... …......
Are you content with your digestion? Yes / No Are you content with your weight? Yes / No
Fluid Intake Daily: < 1 glass 1 - 4 glasses 4 - 8 glasses > 8 glasses Variable
Bowel Motions: Daily Every 2nd day Weekly Constipation Diarrhea Straining Pain Bleed
Exercise: None at all once week twice week three x week > 3 x week Type:...... ………………...... …
Sleep: 8 - 10 hours 6 - 8 hours < 6 hours Irregular Insomnia Sleep apnea Variable
Alcohol: None Occasionally/Socially Weekends 3-4 time a week Daily Variable Binge
Smoking: Do you now? Yes / No If yes, cigarettes per day: ……… Have you ever smoked? Yes / No Quit when: ……….…
Recreational Drugs: Describe and include frequency of use: ...... …...... …......
Stress Levels What challenges you and what do you do to manage it? ...... …...... …......
Anything else? Anything else I should know or you want to tell me? Any questions? ...... …...... ………………..…
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Acknowledgement and Consent
- I acknowledge that the above information, to the best of my knowledge, is correct.
- I confirm that I have had the Healing Space treatmentsand costs explained to me and that I consent to receiving treatments.
- I understand that the treatments are a tactile (touch) therapy.
- I understand that my personal information will be kept in a secure place and will not be released to anyone
without my written permission.
- I understand that a 50% cancellation fee may apply for appointments missed or cancelled with less than 24 hours notice.
Signed ...... Date ......
Confidentiality Policy: All personal information provided is strictly confidential and will not be subject to misuse, loss, unauthorised
access, modification or disclosure. Personal information will not be shared, sold or given to any third parties without consent,
and will only be used or disclosed for its original purpose.