STILL WATERS HEALINGS

CLIENT HISTORY

Name: ___________________________________________Date:___________

Is there any part of your body I should avoid touching during your session?

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FAMILY HISTORY

Relationship status:   M   S   D Other:_____________________     Children: ______  

Relationship with significant others: ________________________________________________

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SPIRITUALITY:  

How would you describe your Spiritual beliefs and practices? ____________________________

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PRESENTING COMPLAINT

Reason for visit today: _________________________________________________________

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When did you first notice the symptoms or condition? _________________________________

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Are you currently receiving treatment for this or any other medical condition? ______________

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HEALTH HISTORY

Please list other health issues or conditions presently concerning you.

 

Please list any and all health issues you have experienced in the past. Please list as many as you can and go back as far as memory will serve. (For example: frequent colds, flu, allergies, broken bones, surgeries, diseases, etc.)

 

Please list any additional comments regarding your health and well being. __________________

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  I have stated all conditions that I am aware of and this information is true and accurate. I will inform the practitioner of any changes in my health status.

Client Signature: _______________________________________ Date: __________________