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Sample History Form


Your certified peak states therapist will ask you to fill out a history form (personal details). This information can be important in helping diagnose your issue, so be sure to fill it out carefully. Note that your therapist may have his own form for this purpose. You can download the sample form by clicking here.



Personal Detail Form
Revision 1.4 Oct 2012


Name                                                Tel                                                Mob

Address:

Email:

Date of birth:

Relationship status:

Occupation:

Contact person (& phone) for emergencies:

Doctors name:

Doctor’s Tel/address:

Current state of health:



Current medical treatments:



Current alternative treatments:



Contagious ailment, current HIV, Hep C, other:



Past medical conditions and treatments:




Drug and Alcohol history:




Other relevant information, events in your life:




Any history of suicidal thoughts or actions, (if so, when):





Revision History
1.1 Oct 27, 2012: Added item on suicidal thoughts or actions.
1.0, Sept 1, 2012: First draft of this webpage of rev 1.3 of Oct 2007.