SPORTS Client Information Sheet

 

Name: _________________________________________ D.O.B. ______________

 

 

Address: __________________________________________ City: ___________________________

 

State: _________ Zip:  ____________ Phone:  __________________ (H)  ____________________(W)

 

Age:  _________ Sex:  ________

 

 

1. Are you now seeing or have you seen a medical doctor or psychologist within the past five years?   _______   
2.  For what?  ___________________________________________________________

 

3. Have you ever had any form of seizure in your lifetime?  ________

 

4. Do you now or have you had any heart problems?   _________

 

5. Do you now or have you had any problems with your breathing?  ________

 

6. Have you used any form of drugs in the last six months?   ________

 

7. Do you have problems sleeping during the night?  ________

 

8. Are you under a doctor's care now?  ________ For what?  _______________________________

 

9. Can you visualize readily with your eyes closed?  ________

 

10. Do you have a fear of high or low places or of possible floating feeling?  ________

 

11. Have you ever been hypnotized?  ________ For what?  _________________________________

 

12. What is your favorite color?  ___________

 

13. What is your favorite place to escape to in your mind from stress?  _________________________

 

14. Do you have any visual problems?  ________

 

15. What are some of your fears?  ______________________________________________________

 

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The above questions are answered true and correct to the best of my knowledge.

 

 

______________________________________                     _________________________

Signature                                                                                                       date