My History

Medical Questionnaire & Indemnity

Please take your time to complete this form. It will give us important information to support our sessions together. Please use a document to record your answers and then paste them into the form below.

(Everything you share in this form is confidential and will only be read by Sandy)

Name

First Name

Last Name

Date of Birth

Telephone Number (Including Country Code)

Please share the main reason for working with Sandy:

Please give details on any current medical problems and any medications you are currently on:

Please give any detatils of any mental health issues you have had / if you have been treated by a psychiatrist / if you have been in hospital for a mental health issue:

PAST HISTORY

PREBIRTH: Was your mother stressed during her pregnancy with you?

Please share anything that may have happened while you were in the womb - including anything your mother may have felt about the pregnancy or any significant events that may have occurred during the pregnancy, for example.

BIRTH TRAUMA: Were you born early/late? Required forceps/surgery? Did you spend time in an incubator?

Please share anything about your birth that may have been stressful for you or your mother, for example.

FIRST 3 YEARS : Who was the main carer? Were you breast or bottle fed? Was there stress in the family during these years?

Please share anything you can remember or how you may have felt, during your first 3 years. Were your parents able to be fully present and emotionally connected to you? Did you have any medical conditions or need to be in hospital during that time in your life, for example?

AGE 3-12 : Are you aware of any stresses at home, primary school or in your family circumstances during these childhood years?

Please share any significant events that happened during this period of your life. Were you bullied, how was your experience of school, were there any issues between your parents, did you have to move home/school, how was your relationship with any siblings, for example?

AGE 13-18: Are you aware of any stresses, traumas or challenges during your teenage years?

Please share anything you found difficult during this time of your life. How was puberty for you, did you start dating anyone and/or how were your early experiences of exploring intimate relationships, for example?

YOUNG ADULTHOOD: Are you aware of any challenges, stresses or traumas during your after school years?

Please share any significant events that may have occurred during these years.

Please add anything else not mentioned above:

Please share any significant events that have happened during your adult life, or anything you feel I should know about not mentioned yet.

CONFIDENTIALITY CLAUSE - Everything discussed within the confines of our work together shall remain confidential and shall not be divulged to any third party. Non-identifying case material may be discussed during supervision. CANCELLATION CLAUSE - I agree to give a minimum of 24 hours notice when canceling my session. Failure to do so will result in full payment of the missed session. INDEMNITY - I undertake the session(s) of my own accord and indemnify the Practitioner from any harm, loss or damage of any nature, whether bodily harm, trauma or any other damages to my person or property resulting from the treatment, whether directly or indirectly.

I have read all of the above and confirm it to be true:

Yes, I agree.