Client Health History Form | Be Vibrant Wellness

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Health History Form for New Clients

To save time in your session, please send me some information about your health history. All information is held securely and is confidential.

Name

Date of Birth

Emergency Contact Name & Phone Number

Please list your current concerns & main reasons for coming. We can discuss details in person.

Please tick if you have any of these conditions:

Headaches

Poor sleep or nervous system overwhelm

Muscle / joint aches or pain; nerve pain such as sciatica down back of legs

Joint replacement, pacemaker or other device

Arthritis or fibromyalgia

Hypertension or diabetes

Blood clots/ thrombosis

Anaemia, dizziness or low blood pressure

Digestive issues e.g. reflux or bloating, loose bowels or constipation

Depression, anxiety or feelings of unhappiness

Fatigue, lethargy or exhaustion

Hearing loss or sensory impairment; or cognitive or learning impairment

Epilepsy or seizures

Have you had any serious accidents, injuries? Or any minor ones recently?

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