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COMPREHENSIVE CLIENT PROFILE FORM
Date/ time of session*
Date of birth*
Place of employment*
Primary physician or other relevant medical professional *
Have you suffered from any of these conditions before? AIDS/HIV Allergies Anemia Arthritis Asthma Backaches Cancer Concussion Diabetes Digestive Disorder AIDS/HIV Allergies Anemia Arthritis Asthma Backaches Cancer Concussion Diabetes Digestive Disorder Emphysema Epilepsy Fractures Gout Heart Disease Hepatitis Hernia Herniated Disk Migraine Headaches Mental Illness Multiple Sclerosis Muscular Dystrophy Neuritis Numbness Osteoporosis Pacemaker Parkinson’s Disease Pinched Nerve Polio Dizziness/Vertigo Prostate Issues Rheum Arthritis Sinus Condition Stroke Thyroid Issues Tuberculosis Tumors Ulcers Other*
Have you gained or lost weight during the last three years?*
List any occupational or other hazards to which you have been exposed to in the past 10 years.*
Have you ever been absent from work or school for longer than one month due to illness? Have you had any accidents as a result of which you have been (partially) disabled? Please describe all injuries and surgeries.*
Please list significant stressful events you have experienced in the past 5 years, and/or any notable childhood trauma, as well as treatment methods used to heal.
What are your hobbies?*
What are some habits that could affect your health? *
What is your major complaint or concern at this time? *
When do symptoms appear? *
How often do you have it? *
Does it interfere with your work, sleep, daily routine, recreation?*
List activities which are difficult to perform*
What treatment have you already received for your condition? How effective were they?*
What are you doing to treat it now? *
Are you currently taking any medication? *
Are your symptoms getting worse, getting better, or staying the same?*
Rate the severity of your overall physical pain in any given week on a scale from 1 to 10. *
Rate your overall stress level on a scale from 0 to 10*
How satisfied are you with your life in these areas, on a scale from 0 to 10, with 0 being completely dissatisfied, and 10 completely satisfied (you are living your dream)? Health, Career, Finances, Friends, Family, Romantic relationship, Personal growth/ spirituality/relationship with self, Fun & recreation, Physical environment (where and how you currently live)
What are the top 3 LIFE goals you would like to achieve in the following year?
What is preventing you from having what you want in life?
What are three characteristics you would like to see in your holistic health coach?*
Would you like a copy of your answers emailed to you?*
If we open our eyes, if we open our minds, if we open our hearts, we will find that this world is a magical place. Suffering is an option!
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