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Date of birth
How did you hear about me
Family situation Single Living alone Living with parents Living with partner Married Separated Other
If a child, parent's names
Spouse/partner's first name
Children: names & ages
What other treatments are you having or have tried
Any past surgeries, serious illnesses, injuries with approx dates
What was your health like as a child?
Was there anything abnormal about your birth?
What areas, problems or goals would you most like help with now?
List any emotional traumas/ episodes, with approximate dates, as far back as you like. (eg. bereavements, divorce, parents split-up etc.)
Any relationship problems including friends, family, work, etc.
Describe a typical day's eating & drinking
What do you do for exercise and relaxation?
Any current drugs & what for?
Medications taken in the past, especially for a long period
Have you ever reacted to any medication Yes No
If yes, what and how?
Do you drink alcohol? Yes No
If so, what and how often?
Do you use recreational drugs? Yes No
If not, have you used recreational drugs in the past? Yes No
Do you smoke? Yes No
If yes, how many a day
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