HAPPINESS AND HEALTH SOLUTIONS

CLIENT QUESTIONNAIRE
Please note: This questionnaire has been designed to provide valuable information to assist in determining how we can help
you. Please answer all questions as accurately as possible. If you need more space please continue on a separate piece of
paper. All answers are completely confidential.

Title………… Name………………………Surname……………………………………………. Date of Birth …………………

Address including Postcode …………………………………………………………………………………………………
……………………………………………………………………………………………………………………………………………
Home Phone …………………………………e-mail………………………………………….Mobile…………………………
Referred by (if applicable ) ………………………………………………………………………………………………………….

Credit/Debit card details

Type of card;-
Name as it appears on card:-
Long Card number:-
Expiry date:-
3 figure card verification number:-

Health Background (confidential)

Present state of health ……………………………………………………………………………………………………………….
Present Doctor ……………………………………………….Doctors Phone Number……………………………………………
Present treatments (including drugs and supplements)………………………………………………………………………….
…………………………………………………………………………………………………………………………………………..
Lifestyle:
Occupation………………………. Marital Status ……………No of children ……Years in present home…….
Was there anything abnormal about your birth ( i.e. premature, method of delivery, presentation, cesarean etc.)
………………………………………………………………………………………………………………………………….
Did you have normal childhood vaccinations………..
What was your health like when you were younger ………………………………………………………………………
List all surgical operations, serious illnesses/injuries/accidents you have had with approximate dates…………….
…………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………..

List any emotional trauma’s that you remember with approximate dates
…………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………..
…………………………………………………………………………………………………………………………………..

Issues you would like to resolve:

How do these affect your life:

How would you prefer things to be:

Please be assured that all answers are in the strictest confidence and that we work to a strict code of ethics.

I understand that Body Code / Psych-K practitioners do not give medical diagnosis or treatment during a session.
I further appreciate that it is my responsibility to consult my GP about any pain, problem or disease that I am presently aware
of, or become alerted to the possibility of during a session.

Signed _______________________ Dated