Jill Chapman Shiatsu // Client Health History Form

Client Health History

Successful health care is only possible when the practitioner has a complete understanding of the patient physically, mentally and emotionally. Please complete this questionnaire as thoroughly as possible. Thank you.

Please submit the following form at least 24 hours prior to your appointment.

Items marked with an asterisk * are required.

First name:*
Middle name:
Last name:*
Email:
Date of birth:	/ / (mm/dd/yyyy)
Gender:	Female Male
Marital status:

1. Please list your main complaint or health concern:
Condition
Past Treatment
How does this condition affect you?
Secondary complaint(s):

2. Please list any medications (prescribed and over-the-counter) you are currently taking:

3. Do you have any reason to believe you may be pregnant? Yes No
If so, how far along are you?

4. Do you have any infectious diseases? Yes No
If yes, please identify:

5. Please list previous surgeries and/or injuries and when they occurred:

6. Emotional (select those that apply to you) Mood Swings Nervousness Depression Bipolar Disorder Anxiety

7. Energy and Immunity (select those that apply to you) Fatigue Slow Wound Healing Chronic Infections Hyperactivity or restlessness

8. Head, Eye, Ear, Nose, and Throat (select those that apply to you) Impaired Vision Eye Pain/Strain Glaucoma Glasses/Contacts Tearing/Dryness Impaired Hearing Ear Ringing Earaches Headaches Sinus Problems Nose Bleeds Frequent Sore Throats Teeth Grinding TMJ/Jaw Problems Allergies

9. Respiratory (select those that apply to you) Frequent Common Colds Difficulty Breathing Emphysema Asthma Persistent Cough Shortness of Breath Other Respiratory Problems:

10. Cardiovascular (select those that apply to you) Heart Disease Chest Pain Swelling of Ankles High Blood Pressure Palpitations/Fluttering Stroke Heart Murmurs Varicose Veins

11. Gastrointestinal (select those that apply to you) Ulcers Changes in Appetite Nausea/Vomiting Epigastric Pain Passing Gas Heartburn Belching Gall Bladder Disease Liver Disease Hemorrhoids Abdominal Pain

12. Genito-Urinary Tract (select those that apply to you) Kidney Disease Painful Urination Frequent Urination Dark Yellow Urine Kidney Stones Blood in Urine Frequent Urination at Night Infrequent Urination

13. Female Reproductive (select those that apply to you) Irregular Cycles Breast Lumps/Tenderness Heavy Flow Vaginal Discharge Premenstrual Problems Bleeding Between Cycles Painful Periods Clotting Menopausal Symptoms

14. Musculoskeletal (select those that apply to you) Neck/Shoulder Pain Muscle Spasms/Cramps Arm Pain Upper Back Pain Mid Back Pain Low Back Pain Leg Pain Joint Pain (if so, where?):

15. Neurologic (select those that apply to you) Vertigo/Dizziness Paralysis Numbness/Tingling Loss of Balance Seizures/Epilepsy

16. Other (select those that apply to you) Cancer Rashes Eczema/Hives Cold Hands/Feet Night Sweats Feeling hot or cold Fibromyalgia Sciatica

Is there anything else I should know?

17. Lifestyle
a. Do you typically eat at least three meals per day? Yes No
If no, how many?
b. Exercise routine:
c. Spiritual practice:
d. How many hours per night do you sleep?
Do you wake rested? Yes No
e. Occupation:
Hours/Week:
Do you enjoy work? Yes No
If not, why not?
f. Nicotine/Alcohol/Caffeine Use:
g. Have you experienced any major traumas? Yes No
If yes, please explain:
h. Television habits:
Reading habits:
i. Interests and hobbies: