MELT Method — Client History & Health Questionnaire

Client Information

Full Name

Date of First Visit

Address

Phone Number

Email

Date of Birth

Age

Weight

Height

Marital Status

Number of Children & Ages

Occupation

Handedness

Right handed Left handed

General Health History

List any pain or dysfunction present today — most to least important, with approximate date of onset

Have you seen a GP or specialist for any of these problems?

Was there any treatment or diagnosis given? If yes, what was it?

Has the condition changed with treatment?

Commitment to health goals (1 = low, 10 = high)

General energy level (1 = low, 10 = high)

Please list all medications you are currently taking:

Are you experiencing any side effects?

General Questions

Check all that apply

Difficulty falling/staying asleep Depression or anxiety Wakes at night for bathroom Can fall back asleep easily Extreme stress / pressure daily Currently smokes Drinks alcohol Drinks coffee

Average hours of sleep per night

Water per day

Meals per day (average)

Do you exercise regularly? If yes, what type(s)?

Smoking / alcohol / coffee — if any, please note frequency

Have you ever been diagnosed with cancer? If yes, what type?

Please list any surgeries (major or minor) you have undergone:

Medical History — Check All That Apply

General Musculoskeletal System

Nervous System

Dizziness or vertigo Frequent headaches or migraines Loss of balance

Nose & Sinuses

Sinus infections Allergies Difficulty breathing Nose surgery or reconstruction

Reproductive System

Prostate issues or enlargements Fibroids, cysts, or endometriosis Frequent cramping Heavy flow during period

Release of Liability

Initials

Client Signature

Date

Thank you.