Confidential Client History Form Remedial Treatment











    GENERAL HEALTH SCREEN



    LIFESTYLE HABITS









    Previous Diagnostic / Surgical / Illness / Accidents


    Health History




    (including aspirin, ibuprofen, vitamins, herbs, homeopathic and naturopathic remedies)


    (location and duration or onset)

    (how it happened - position / direction etc)

    (constant / with movement / with activity / sharp / shooting / dull / aching etc)

    (activities / posture / stressors)

    (movement/rest/posture/heat/cold)

    (include all health care types – Complementary Medicine Practitioner and / or Medical Doctor, Physiotherapist, Osteopath, Chiropractor, Dentist)

    Please indicate from the diagram below, the area that are affected or that are painful.



    Only sign below if the above information is understood and has occurred