“Medical Wellness & Life Balance”
Client Name: _____________________________________________ Date: ____________
I am on the following medication: Birth Control_______________ Is there a Chance you are pregnant?
_____ If on CARBATROL, TRILEPTAL, or DEPAKOTE and female, what birth control method do you
use?_________________________________________________________________________________________________
Take HERBAL REMEDIES? Specify, ________________________________________________________________________
Vitamins? _______________________________________________________ ALLERGY SHOTS? ______________________
Do you have Mitral Valve Prolapse?_____________
LIST YOUR ALLERGIES: ___________________________________________________________
CURRENT MEDICATION you are taking (include meds you were taking on your last session here).
List each medication and daily dosage.
1. _______________________________! ________!
2. _______________________________ !__________
3. _______________________________! ________!
4. _______________________________! __________
5. _______________________________! ________!
6. _______________________________! __________
New Medication since your last session. Please include over the counter medication:
1. _______________________________! __________!
2. _______________________________! __________
3. _______________________________! __________4. _______________________________!
Other doctors, psychologists, coaches, or ministers you have seen since your last session:
______________________________________________________________________________________________________________
***Positive Changes in Your Life Since Last Session: ____________________________________________________
______________________________________________________________________________________________________________
***Challenges In Your Life Since Last Session: _________________________________________________________
______________________________________________________________________________________________________________
***Things I would like to discuss and or evaluate with the doctor, nurse, coach, or minister today:
______________________________________________________________________________________________________________
______________________________________________________________________________________________________________
__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________
Return Date: _________________ Coach(es): _________________________________________ Date: _________________
Cerebral Palsy Cerebral palsy (CP) is an ‘umbrel a’ term used to describe a group of chronic movement or postural disorders. “Cerebral” refers to the brain and “palsy” refers to a physical disorder. Cerebral palsy is caused by faulty development of or damage to motor areas in the brain, causing disruption of the brain’s ability to control movement and posture.A diagno
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“Medical Wellness & Life Balance”
Client Name: _____________________________________________ Date: ____________
I am on the following medication: Birth Control_______________ Is there a Chance you are pregnant?
_____ If on CARBATROL, TRILEPTAL, or DEPAKOTE and female, what birth control method do you
use?_________________________________________________________________________________________________
Take HERBAL REMEDIES? Specify, ________________________________________________________________________
Vitamins? _______________________________________________________ ALLERGY SHOTS? ______________________
Do you have Mitral Valve Prolapse?_____________
LIST YOUR ALLERGIES: ___________________________________________________________
CURRENT MEDICATION you are taking (include meds you were taking on your last session here).
List each medication and daily dosage.