Client Stress History Form

Please note: I am not a medical doctor. By law, I cannot diagnose, treat, cure or prevent any disease. I am not a licensed psychologist. By law, I cannot diagnose, treat, cure or prevent any psychological disorder or disease. I am a Certified Biofeedback Specialist and I do not diagnose, treat, cure, or prevent any disorder or disease. I do not dispense, nor recommend, any drugs of any kind. I do not treat medical or psychological conditions. - Marion White PhD

Please fill out this form to help me understand your stress history before your first appointment.
PLEASE FILL IN THE FORM COMLETELY. USE THE "TAB" KEY TO MOVE BETWEEN FIELDS. CHECK THE VERIFICATION SYMBOLS CAREFULLY BEFORE CLICKING THE SUBMIT BUTTON.

Name

Email

Address

City

State

ZIP

Phone (home)

Phone (work/cell)

Birthdate

Time of Birth

Birthplace (City/State)

No. of organs removed (all teeth = 1, for example)

No. of prescription drugs

No. of cigarettes smoked per day

No. of steroid drugs taken

No. of metal fillings

No. of street drugs taken

No. of allergies

No. of unresolved mental factors (Greed, resentment, anger, etc.)

I am responsible for my body (0=no, 10=yes)

%fat in diet (average is 45%)

Personal stress (0=none, 10=max)

No. of sugar products per day

No. of exercise sessions per week (20 mins. or more)

No. of alcoholic beverages per day

No. of caffeine products per day

No. of extreme toxic exposures per year (chemo, radiation, etc,)

No. of major traumatic injuries in lifetime (mental, emotional, physical)

No. of major infections

Glasses of water you drink per day

Pounds you feel over/under weight

Please indicate any areas of interest for the SCIO session

Personal History

Referred by

Please enter the symbols in the image

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