PERSONAL INFORMATION FORM
Please complete all questions. All information is filed as CONFIDENTIAL and will be supplied to no person or organization unless requested in writing by you. DATE COMPLETED___________

Full Name:___________________________________Name like to be called______________
Sex _______Age_____ Birth Date_____________Weight(lbs)________height(inches)________
Mailing Address______________________________________________________________
City ______________________________State____________Country__________Zip_______
Preferred E-mail Address________________________________________________________
Do you have a website?________Address___________________________________________
Home Phone (___)_________________Work Phone(___)______________
Preferred Phone and hours_______________________________________________________
Home Fax___________________________Work Fax_________________________________
Occupation___________________________________Title/Position______________________
Marital Status__________Spouse’s Name____________________Anniversary Date_________
Children (age & sex)____________________________________________________________
Spouse”s Occupation____________________________________________________________
Education:(highest grade or degrees held)____________________________________________
Explain in a few words your Spiritual beliefs:_________________________________________
______________________________________________________________________________
My most Important Challenge in Life is :_____________________________________________
______________________________________________________________________________
Explain any current Health Issues you are experiencing:_________________________________
______________________________________________________________________________
______________________________________________________________________________
List any current Medications & Supplements and their purpose:___________________________
______________________________________________________________________________
______________________________________________________________________________
Have you ever been treated for an emotional challenge?_______If yes, please explain_________
_____________________________________________________________________________
Have you ever been hypnotized before?______If yes, please explain_______________________
______________________________________________________________________________
Any previous efforts to solve these challenges?__________Results________________________
______________________________________________________________________________
______________________________________________________________________________
Do you have any fears or phobias?________Please explain______________________________
______________________________________________________________________________
PERSONAL INFORMATION FORM PAGE 2

Special interest or hobbies:________________________________________________________
______________________________________________________________________________
List at least five (5) Short Term Goals (one year or less)_________________________________
______________________________________________________________________________
______________________________________________________________________________
List at least five (5) Long Term Goals (one or more years)_______________________________
______________________________________________________________________________
______________________________________________________________________________
Describe, in a few words, how you see yourself in one year______________________________
______________________________________________________________________________
______________________________________________________________________________
In Five Years:__________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
What is your Ultimate Goal in life?_________________________________________________
_____________________________________________________________________________
______________________________________________________________________________
This is a checklist of your concerns. Please place the appropriate number beside each item that applies to you. On a scale of 1 (highest priority) to 10 (lowest priority). You may use a number more than once, and use as many different numbers as you can.
___need a job ___weight problem ___poor organization
___worn out by job desired wt?______ ___would like to inc. income
___cannot save money ___eat too much _sweets present$__________/yr
___cannot get ahead __junk food__other desired$__________/yr
___problem w/_coworker ___not enough exercise when?___________
_employee _boss ___dissatisfied w/appearance ___desire a promotion
___dislike job__school why?_______________ ___what to change
___too much spare time ___want to quit smoking __business__jobs
___bad habits_______ ___difficulty getting to sleep ___work too dull
___drug problem ___cannot stay asleep ___afraid to take risk
which drug_____ ___poor memory ___blames other
_____________ ___studying is dull ___want to know my life
___drink too much ___read too slow mission
how much of what ___poor concentration ___need more goals
_______________ ___procrastinate a lot ___lack of skills
PERSONAL INFORMATION FORM PAGE 3

___lack of motivation/ambition ___bad dreams ___cannot get up mornings
___trouble making decisions ___feel awkward ___get sick a lot
___lack of education ___cannot express emotions ___fear of __health___mental
___trouble with children which______________ state getting worse
___trouble w/loved ones ___dislike people ___aging too fast
___quarreling at home ___frequent crying ___lack of energy
___no time to relax ___different from others ___blood pressure __high__low
___need more fun how________________ ___menopause difficulty_____
___unwanted emotions ___fear responsibility ______________________
____________________ ___quick to anger ___allergies to______________
___wanted emotions that are absent ___too critical of others ______________________
_________________________ ___violent how_________ ___chronic pain
___Depressed __________________ ___spiritual problems
___fear/phobia of_____________ ___verbally abusive when angry ___hard to meet people
___afraid of people ___do not trust others __business___personal
___low self esteem ___too sensitive ___still grieving over________
___thought about suicide ___feel sad frequently died mo.____yr____
___fear of dying ___do not communicate ___feel shy
___too emotional ___speech problems_________ ___feel lonely
___too nervous ___fear public speaking ___want a love relationship
___guilt feelings ___lack of skill ___sexual difficulties
___negative reaction to stress ___poor vision ___desire more sex
___difficulty relaxing ___desire to see well wo/glasses ___unhappy marriage
___easily influenced ___hearing impairment ___divorce
___am not assertive ___too pessimistic ___relationship breakup
___legal problems ___difficulty making friends

Thank you. Email to wellnessdoc@mac.com or mail to P.O. Box 544, Rabun Gap, Ga. 30568. We will call you for any appointment.