Personal and Health Data Form

Personal Information: (Please print or write legibly.) Date of initial visit _______________

Name _______________________________
Address ______________________________________ Date of Birth ________ Age ___
City _________________ State ____ Zip _______ Sex: M ___ or F ___ Marital Status ____
Home Phone ___________________ Work Phone _______________
Occupation (s) _____________________________ Referred by ____________________
What is your goal/concern for today's session?

What is your previous experience with professional breath or bodywork?

Do you experience and difficulty lying on your front or your back?

Life Style: Nutritional or eating habits _____________________________________
Do you use : Tobacco ______ Alcohol ______ Caffeine ______ Non-med Drugs ______
Posture assumed most of the day _____________________________________________
Sleep habits ________________________ Regularity of Bowels ____________________
Methods of exercise ___________________ Leisure enjoyments ____________________

Health History:

___ Hypertension	___ PMS/painful menstruation	___ Osteoarthritis
___ Heart disease	___ Easy bruising	___ Rheumatoid arthritis
___ Arteriosclerosis	___ Skin rash	___ Fibromyalgia
___ Varicose veins	___ Abscess or open sore	___ Herniated disc
___ Phlebitis	___ Skin Sensitivity	___ Inner ear problem
___ Epilepsy	___ Allergies	___ Pregnancy (now)
___ Headaches	___ Herpes 1 or 2	___ Fluid retention
___ Cancer/malignancy	___ HIV positive or AIDS	___ Hepatitis A, B, or C
___ History or mental illness	___ Osteoporosis	___ Diabetes I or II

List any surgeries, fractures, or injuries that have occurred within the last year:

List areas of musculoskeletal pain or stiffness:

List past injuries, surgeries, or major illnesses and their year of occurrence:

List any history emotional difficulties, abuse, and counseling:

Are you under medical care or supervision now (please explain)?

List any current medications and the condition for which they are a treatment:

Please note: Contact lenses ___ Dentures ___ Hearing aid ___ Pacemaker ___ Joint replacement ___
What specific aspects of your life are stressful?

Do I have your permission to contact your physician should the need arise?
Name of Physician(s) ___________________________________ Phone __________________

The above information will be treated confidentially in accordance with your wishes. In order to maximize the effectiveness and safety of our work together, please give your feedback during and at the end of the sessions This will help in tailoring our work together to best meet your needs.

I have read the above information and understand that it is my responsibility to inform the therapist of any changes in my health. I understand that this work does not constitute medical treatment. It is a form of health maintenance and wellness education. I take responsibility for alerting my therapist to any physical conditions that may be affected by this work. I understand that Robert Clark and the health practice with which he is associated will not share any of my personal health information with any third parties without my express written consent unless required to do so by law.

Signature ____________________________________________ Date _____________