Client Profile

This is the paperwork I would like you to fill out if you were to come to me. For a printable copy in Microsoft Word Format, please scroll down to the bottom of the page.

Date:
Personal Information
Name
Address
City Zip
Phone day
Phone eve
Pager / Cell / Fax / Other (Type)
Pager / Cell / Fax / Other (Type)
E-Mail Address
Age Birth Date Time of Birth	- / / -
City / State / Country of Birth	Age Month Day Year Time
Height / Weight	/ /
Blood Pressure (high/low/normal)
Marital Status/ Number of Children
Notify in case of emergency
Address/ Phone

Occupation
Employer

Physician Information
Doctor’s Name
Address/Phone
Additional Health Professionals (Accupunturist/ Chiropractor/ Holistic/ Herbalist etc.) Name and Phone #


Are you currently seeing a psychologist or Metal Health Professional? No Yes Name

Reason for visit (Circle or write in)
Wellness/Relaxation Stress	Spiritual/Energy/Psychic
Specific Condition: Include Date of First symptoms
Onset - (Circle) Gradual or Sudden Sickness or Injury
Your Doctor’s Diagnosis

Personal History
Injuries
Medical Condition
Do you have any chronic conditions? Yes No
Do you have any infectious conditions? Yes No

Other Treatments/ Medications
Medication by Physician
Orthopedics
Diets
Homeopathy/Herbal Medicines
Acupuncture
Chiropractic
Nutritional Counseling
Psychological Counseling
Energy/Psychic/Alternative
Other

Personal Habits
Smoke? No Yes How Much
Drink Alcohol? No Yes How Much
Diet / Nutrition (Healthy? Junk Food? Vegetarian? Calorie counting? Etc.)
Do you Exercise (Types and Frequency) No Yes
Do you meditate? No Yes

YOUR MEDICAL PROFILE

Name:

Please indicate whether you have had or currently have any of the following conditions:

	Have Had	Have Now
	When?

High Blood Pressure
Phlebitis
Thrombosis
Stroke
Varicose Veins
Edema
Arthritis
Gout
Bursitis
Tendonitis
Hernia
Whiplash
Sciatica
TMJ Pain (Jaw / teeth grinding)
Low back Pain
Stiff Neck
Other Chronic Aches
Allergies (List)

Headaches
Migraine
Tension
Other
Chiropractic Care
Types of Adjustment
Growth or Lump under skin
Cancer (Type and status)
Surgeries
Tuberculosis
Hepatitis
HIV Positive/AIDS
Sexually Transmitted Diseases
Burns
Surgery (Type and status)
Rash
Eczema
Recent Scars or Cuts
Ulcer
Constipation
Heartburn
Excessive Gas
Colitis
Abortions
PMS
Menstrual Cramps
Irregular or problem menstrual cycles or conditions
Torn Muscles, ligaments, or tendons
Broken Bones (list)


Any other condition you consider important to share

Do you wear Contact Lenses? Yes No

Do you wear Dentures? Yes No

Do you any mechanical/electrical implants?

(IUD, Pacemaker, etc.) Yes (type) No

Preferred Food taste (circle) Sour Bitter Sweet Salty Spicy

What medical conditions do either of your parents have, which may be hereditary? i.e. Cancer, High blood pressure, Cholesterol, Diabetes, etc.

PERSONAL PROFILE

What are your main tension areas?

What conditions do you have, either illness or injury, that are either chronic or repetitive?

In general, your illnesses/injuries and tend to be located . . . (circle one each line)

Left side Right side Evenly (both/neither)

Top half Bottom half Evenly (both/neither)

If top half, Mostly head Mostly chest abdomen

Torso Limbs Evenly (both/neither)

What do you do for relaxation / centering / rejuvenation and how often?

1. Have you ever been a victim of sexual, physical or emotional abuse?

Yes

2. Do you consider yourself to be presently a victim of anyone or anything at all?

Yes

3. Do you feel that people tend to take advantage of you?

Yes

4. Are you currently in psychological counseling of any kind?

Yes

5. Do you have a drug, alcohol, or substance abuse condition?

Yes

6. Have you ever felt that a medical doctor has ever behaved in any way inappropriately towards you during a medical visit?

Yes

7. Are you currently in recovery?

Yes

8. Do you have any problems or issues with being touched? Do you tend, or have you tended to believe that anyone who would want to touch you has ulterior motives?

Yes

9. Do you tend to have or cause a lot of “drama” in your life?

Yes

10. Have you called appealed to the courts, the police, or “911” in the past two years?

Yes

11. Do you suffer from acute anxiety attacks or panic attacks?

Yes

12. Have you ever been diagnosed with PTSD (Post Traumatic Stress Disorder)? Have you ever had an incidence of para sympathetic hyper inhibition?

Yes

13. Do you have a history of doing things for which you later have great remorse, anguish, or regret?

Yes

14. Do you have trouble speaking up for your self or expressing yourself?

Yes

15. Do you suffer from any condition which would cause you to “freeze up” or be in a state where you would not be capable of expressing comfort and discomfort clearly?

Yes

16. Do you believe, or has anyone suggested to you, that you are mentally incompetent, or in any way impaired in your rational decision making processes?

Yes

List any areas, features conditions about yourself with which you are most dissatisfied. What are your “worst” features, either physically, mentally, emotionally, spiritually, etc.? In other words, if you could change things about yourself, what would they be?

List any areas, features conditions about yourself with which you are most satisfied. What are your “best” features, either physically, mentally, emotionally, spiritually, etc.?

Are there additional sources of concern in your life that you wish to mention?

Is there anything else that you wish to disclose, that could have an impact on your session?

I understand that Joseph Willenbrink is not a doctor and does not treat, diagnose, prescribe, nor perform chiropractic adjustments. I understand that Joseph Willenbrink is not a massage therapist, and I am not expecting anything remotely related to a massage My doctor approves of my receiving physical manipulation. I have read, and understand and agree to, the attached information. I understand that these sessions are unconventional, and I accept them as recreational only. The concept of “implied consent” has been explained to me thoroughly, and I understand and agree to it completely. I explicitly grant permission to Joseph Willenbrink to touch me where and how he sees fit, understanding that he is not a medical doctor, and that he may not be aware of my medical conditions and their implications. I take responsibility for seeking medical care, and for my health.

Name (printed)

Signed:

Date :

For a copy of this form in Microsoft Word format, suitable for filling out and printing,