Download Client Medical History form

This information needs to be completed and returned at least 48 hours before your appointment
to allow me sufficient time to prepare for your visit. It would help my preparation for your
appointment if you could complete this form as fully as possible.
Thank you, Ellie
Client Medical History form
Name:
D.O.B :
Address:
Contact telephone number:
Email:
GP address:
Previous Therapists:
Employment:
Hobbies:
Right or left-handed
Visual weight (under, average, over, obese, morbidly obese)
Diagnosed medical conditions
Circulation problems (Heart, high/low BP, poor circulation)
Respiratory (Asthma, bronchitis, hay fever)
Skin disorders (dermatitis, eczema, sensitivity, fungal infections)
Muscle or joint (fibromyalgia, rheumatoid arthritis)
Neurological (sciatica, epilepsy, migraines)
Urinary (cystitis, thrush, kidney)
Immune system (prone to colds, reduced immune status)
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Gynaecological (PMT, menopause, HRT, irregular periods)
Hormonal (Diabetes)
Digestive (indigestion, heartburn, constipation, IBS)
Stress-related or mental health (depression, anxiety, panic attacks, mood changes)
Other (eg Cancer)
Medication & Supplements (include steroid history)
NOTES:
Is there a GP / Consultant diagnosis?
Did your GP refer you to physio/chiro/osteo/specialist?
Physical traumas / injuries / accidents and approximately how long ago, including any problems at
birth for example broken limbs, head trauma, concussion, twisted ankle. Pleas indicate below:
Feet
Ankles
Knees
Hips
Pelvis
Spine - lumbar, thoracic, cervical
Ribs
Skull
Shoulders
Elbows
Wrists
Hands
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Insertions (pins/plates/orthotics/dentures/prostheses/lenses etc)
Relevant imaging details (X-ray, MRI, other scans)
Number of pregnancies……….Number of children………………..Details of birth(s) and dates if relevant
(miscarriages, normal birth, C-section, medical intervention such as Epidural Anaesthesia (given at C,
T or L site), Spinal Block/Anaesthesia (via catheter and below L2, and one-shot normally) ,
Episiotomy (perineum)
Details of other children/adults cared for by client
General anaesthetic – when and why (scars, from trauma or surgery- mark on Body Map)
Other investigations procedures (Colonoscopy, endoscopy)
Dental work (what , when & outcome)
Sleep pattern eg waking during night, night sweats / emotional health / tiredness / energy levels
NOTES:
Social History (e.g. dependants, bereavements, family circumstances, stress, emotional trauma and
‘stress bucket’). Mark your stress level on an average day on scale below
GREAT ------------------------------------------------------------------------------------------------- AWFUL
Family history (incl. incidence of client’s symptoms in the family)
NOTES:
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Scars, tattoos
to be completed at initial consultation
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