Print out, complete, & bring this form with you on your first visit to the doctor.

Last Name: ___________________________ First Name: ________________
Middle Initial: ____

Date: ___________________

Address: _____________________________________
Address: _____________________________________
City: _________________________ State: ____ Zip: __________

Home Phone: _______________ Work Phone: _______________
Date of Birth: ____________ Age: _____

Sex: _______ Marital Status: ____________________

How did you learn about our office/services?

__________________________________________________________________

Have you ever used, or are you now using, any of the following relaxation/improvement techniques:

___ Self-hypnosis ___ Hypnotherapy ___ Deep Relaxation
___ Meditation ___ Yoga ___ Centering ___ Biofeedback

Have you been under a doctor's or therapist's care for an emotional or psychological problem? ___ Yes ___ No

If yes, give reason:

__________________________________________________________________

Have you been under a doctor's care in the last year for any illness, medical treatment or surgery? ___ Yes ___ No

Conditions for which you take medications:

__________________________________________________________________

Check off anything below that applies to you , or anything that you wish to change in your life:

___ Achieve personal goals ___ Improve self-motivation
___ Develop new skills & abilities ___ Improve school performance

___ Build self-confidence ___ Personal change(s) I wish to make
___ Athletic Performance ___ Personal problem(s) you can't resolve

___ Persistent emotional upset ___ Disturbing/painful feelings
___ Can't express feelings ___ Can't confront old feelings

___ Can't relax ___ Can't cope ___ Worry a lot ___ Anxiety / panic
___ Troubling thoughts ___ Poor self-esteem /self-confidence

___ Excessive fatigue ___ Fears / phobias ___ Feel Sad / Depressed
___ Feel Anger ___ Have lost my religious / spiritual beliefs

___ Care for Others & never have time for Myself
___ Unwanted habits or desires ___ Obsessions / Compulsions

___ I'm a Perfectionist ___ I'm very Controlling ___ Worry what others think of me
___ I'm a clean / neat freak ___ I'm a shopaholic

___ Losing control ___ Disturbing dreams ___ At the end of my rope
___ Not participating in life ___ Feel like I can't be helped

___ Don't like who I am ___ Feel hopeless
___ Contemplated or Attempted Suicide ___ Feel I should never have been born

___ High blood pressure ___ Heart disease ___ Diabetes ___ Cancer
___ Stress & tension ___ Headaches / Migraines ___ Body pain

___ Arthritis ___ Irritable Bowel ___ Fibromyalgia ___ Chronic Fatigue
___ M. S. ___ Parkinson's ___ Eating disorder

___ Ringing In Ears ___ Prolonged or serious physical illness
___ Physical disorder / degeneration ___ Difficulty sleeping

___ Stress related illness ___ Strong food cravings ___ Control my weight
___ Stop using drugs / alcohol ___ Sleep apnea / snoring

___ Develop new relationships ___ Making relationship decisions
___ Enhancing your marriage ___ Eliminating marital difficulties

___ Recovery from divorce / separation ___ Recovery from abuse
___ Recovery from loss / death

___ Confidence to build new career ___ Difficulty with children
___ Parent / child conflicts

___ Remove sexual inhibitions ___ Improve sexual communication
___ Restore / Enhance sexual desire ___ Improve sexual pleasure

___ Infrequent sex ___ Restore sexual performance
___ Uncomfortable / Painful Intercourse ___ Increase sexual responsiveness

___ Difficulty achieving orgasm ___ Sexual addiction ___ Male Impotence

___ Can't get pregnant ___ Miscarriages ___ Difficult pregnancy
___ Depression / Sad after pregnancy

___ Irregular menstrual cycle ___ Gynecological disorders
___ Moderate / Strong PMS ___ Menstrual Pain / Difficulties

___ Breast Pain / Tenderness / Cysts ___ Ovarian Cysts
___ Chronic Pelvic pain

In order of importance, list the three "most significant" self-improvements, problems or difficulties you wish to work on:

1. __________________________________________________________________

2. __________________________________________________________________

3. __________________________________________________________________