NAME: _________________________

DATE: __________________________

Dear patient
In order to render complete and comprehensive care. It is necessary to summarize by decades what happened in your life important to your physical mental and spiritual healing. This essential data or information will assist the therapist with her evaluation and enable your care to be as comprehensive as possible. We realize this will be time consuming and we appreciate the effort.

Example: Age 0-10- born july8: 1951, 10 lbs. 6.oz in hospital the 4th of 5 children, mother had blood pressure, no complications for me, I had eczema in preschool, hay fever started at age 6 fell out of tree fractured skull; age 7 hospitalized 6 weeks- bad case of measles age 7 with pneumonia- held back in school because of missed time dad died age 8 mom remarried age-9 headaches and unhappiness for 1 year and loss of weight- wore glasses- did well in school and become involved in church activities.

Try to be as complete as your memory will allow. Be concise and do not exceed space provided. If possible.

Age 0 -10

Age 10- 20

Age 20-30

Age30-40

Age 40- 50

Age 50-60

Age 60-70

Age 70 plus