Full Name
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First Name
Last Name
Preferred Name (if applicable)
Email
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Phone
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Country
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Date of Birth
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Gender
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Current and (if applicable) past occupation
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Relationship Status
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Children
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Emergency Contact Name & Number
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General Practitioner’s Details
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Name, Address & Contact Number
Do we have your permission to contact your GP if it becomes necessary to do so?
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What are your main goals or intentions for our work together?
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What issues or concerns are you currently experiencing that you'd like help with?
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Describe any significant past history concerning your physical body
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Include any accidents, medical intervention, medication, symptoms, toxin or drug exposure, if you have ever been unconscious.
Describe any significant past history concerning your mental and emotional life?
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Include any major life stresses, traumas or events, as well as any medications or mental and emotional symptoms.
How is your mental and emotional life presently?
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Please include any current mental health challenges, diagnoses, and medications.
Do you currently menstruate?
If yes, please provide any details that feel relevant to you, such as:
- Approximate length of your full cycle (from Day 1 of your period to the next)
- How many days you typically bleed
- Flow (e.g. light, moderate, heavy, varies)
- Spotting (before or after your period)
- Any symptoms or changes you notice throughout your cycle
Do you currently take any supplements?
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Do you smoke and/or consume alcohol?
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Do you or have you used recreational drugs?
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What type of practitioners and health care providers have you consulted in the past and how helpful have they been?
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Who do you have on your health team presently, and how long have you been seeing them?
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How often do you currently exercise or engage in physical activity?
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Please include the type of activity (e.g. walking, gym, yoga, etc.), how often you do it (times per week), and the average duration.
How would you rate your current stress levels?
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On a scale of 1 to 10 (1 = very low, 10 = very high), how stressed do you feel most days? Feel free to share anything that contributes to your stress or helps you manage it — such as work, relationships, life changes, or coping tools you use.
Do you currently engage in any mindfulness or grounding practices?
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This could include things like meditation, breath work, mindful walking, journaling, time in nature, creative activities, or anything else that helps you feel present and connected.
If so, what do you do, and how often?
Do you make time for rest and relaxation outside of sleep? What helps you unwind or recharge?
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How would you describe your sleep?
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What time you usually go to bed and wake up? How many hours do you usually get? Do you wake feeling rested? Do you have trouble falling or staying asleep?
Do you have any sleep habits or routines that support (or disrupt) your rest?
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You might like to include things like:
If you get morning sunlight, Screen use before bed, Evening rituals, Bedroom environment (e.g. light, noise, temperature), Anything that helps or hinders you from falling or staying asleep.
Do you snore or breathe through your mouth while sleeping?
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If you’re not sure, has anyone ever mentioned it to you?
How connected do you feel to your community, friends, or family?
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Do you have people you can talk to and feel supported by?
Do you have any outlets for creativity or self-expression?
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What currently brings you joy or a sense of purpose in your life?
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How do you currently view yourself and your wellbeing journey?
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Do you feel like you’re constantly trying to fix or improve yourself, or do you feel a sense of acceptance for where you are right now?
How much of your day is spent trying to manage your physical symptoms and/or your mental health? (if applicable)
You might consider things like time spent researching, tracking symptoms, supportive routines. Does it feel like this takes up a small, moderate, or significant part of your day?
Do your symptoms ever feel like they’re getting in the way of fully living your life—either day-to-day or when thinking about your future?
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Do you find yourself frequently ruminating on your symptoms or how you’re feeling?
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Do you find yourself often ruminating on past or future situations, conversations, or events?
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How much time do you currently have to yourself on a typical day or week—without work, family, or other obligations?
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This helps me tailor your plan in a way that feels realistic and supportive for your lifestyle, whatever that looks like.
Is there any other information that may be relevant to your care that has not been covered?
Nutrition and Lifestyle Consent
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I consent to the collection and storage of my personal and health information for the purposes of receiving nervous system, nutrition and lifestyle support.
I understand that all information I provide will be kept confidential and securely stored, in accordance with data protection laws. I understand that the advice and guidance provided is not a substitute for medical diagnosis or treatment, and that I should consult my GP or healthcare provider where necessary.
I confirm that the information I have provided is accurate to the best of my knowledge.
Do you consent to receiving treatment in the form of Spinal Energetics?
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I confirm that I have disclosed any relevant physical, emotional, or mental health conditions that may impact my sessions.
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