Client Initials:
Age:
Case Study Number:
Primary Reason for Visit? *
When did you first notice it? *
What brought it on? *
Describe any stressors occurring at the time: *
What activities provide relief? *
What makes it worse? *
If yes, please provide details:
If yes, please provide details:
If yes, please provide details:
If yes, please provide details:
If yes, what type?
If Yes, please give reason(s):
Practitioner Phone Number:
Practitioner E-Mail Address:
If yes, please state what you are on:
If yes, please state specific allergen and reaction:
If yes, please list year and type of surgery and/or recent procedures:
If yes, then please list:
If yes, then please list:
If yes, please give full details:
If yes, please give full details:
What is your opinion of yourself? *
If possible, please describe the most negative emotions you experience: *
When do you most often feel this emotion? *
Where are you when you feel this? *
If yes, please provide details:
If yes, please describe briefly:
What hobbies or activities do you have that provide you with a sense of accomplishment? *
Describe your exercise routine (type, frequency): *
What changes would you like to achieve in 6 months? *
Changes in one year? *
If yes to any of these, please provide details:
If yes, details:
If yes, details:
If yes, location?
If yes, details:
If yes, type?
Relationship?
If yes, type?
Relationship?
If yes, when?
Type?
If yes to any of these questions, when?
What was this like for you?
If yes, details:
If yes, details:
If yes, details:
If yes, details:
If yes, describe flow, stream, strength of stream:
When did you first notice these symptoms?
If yes, describe:
When did you first notice these symptoms?
If yes, describe:
If yes, describe:
If yes, please list:
Results of PSA (Prostate Specific Antigen) test if known:
Date of Test?
Results of sperm count (if applicable and known):
Date of Test?
Additional Comments: