Client Form

Client Form

Bowen & Craniosacral appointments
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
What is your gender?
Contact Number
Email Address
example@example.com
Emergency Contact Details
Name, relationship and phone number
Primary reason for visit (please explain)
Please include main areas of complaint, pain, tension (please explain)
Check the conditions that apply to you:

AsthmaCancerHeart diseaseDiabetesHypertensionPsychiatric disorderEpilepsyHeadachesMigrainsBack painNeck painShoulder painFrozen shoulderTMJ/JawPins & needles in arms/handsPins & needles in legschronic fatigueDizzinessAnxietyDepressionPTSDMenopausal symptomsPremenstrual symptomsPelvic/hip painNumbness in handsNumbness in feetSkin problemsTinnitusJoint & muscle painUlcersFibromyalgiaHep B/CAutoimmune condition/sLow blood pressureBlood clotsDental workHypoglycemiaScoliosisOther
Have you had any other treatments in the past for your current health concern
Please list treatments
Are currently pregnant

YesNo
If yes, how far along
Please state if there are any complications
Have you had surgery

YesNo
Please give details
How recently and please describe stating any complications
Past or recent physical injuries
Include fractures or dislocations
Do you have any other physical, neurological or mental health conditions of which I should be aware of
If yes please describe
Are you currently taking any medication?

YesNo
List Medication
What kind of tobacco products? How long have you used/been using them?
Do you use any kind of illegal drugs or have you ever used them?
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?

DailyWeeklyMonthlyOccasionallyNever
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