Spinal Immersion Intake form

Health Survey

Please fill out this health survey
Name

First NameLast Name
Date

MonthDayYear
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Preferred Contacts

Phone CallEmailPhone MessageOther
Birth Date

MonthDayYear
Age
Ex:23
Gender
Please enter your emergency contact information:Their name, relationship to you & phone number
Are you interested to become a Spinal Attunement Practitioner?

YesNoStill not sure
Do you have any diet wishes?
How would you like to pay?

Privat invoiceBusiness invoiceCash
Can you provide us please your invoice details? *Note: invoices should be paid prior to the Spinal Immersion
Medical
Are you using medicines? What are you using them for?
Are you pregnant?

YesNoN/A
Are you nursing?

YesNo
Do you have a history of physical or psychological health issues?If yes, please elaborate on what they were/are, treatment sought & if resolved or ongoing
Do you have a history of burn out / adrenal fatigue?
Do you experience:select all that applies

Unexplained painPersistent pain that won't go awayPain that is present without any movementNight pain, pain that wakes you at nightNight Sweats
Do you experience any changes in sensation (pins and needles / numbness / burning / itching / sharp pain) in both arms or legs?Please specify
Do you experience any changes in your bladder and bowel? This may be changes in sensation or onset of incontinencePlease specify
Do you experience:select all that applies

DizzinessFaintingDifficulty swallowingDifficulty SpeakingDouble visionNausea
Are there any other health issues I should be aware of?Please list all past and current health issues (year) below
Are there any other medical conditions / diagnoses we should be aware of?Please list all past and current medical conditions / diagnoses (year) below
Any past or current use of drugs or alcohol?Please specify whether past or current and approximate intake
Womb Health
How would you describe your current relationship with your womb?
Pregnancies: Number of pregnancies, and description of complications, miscarriages, abortions, or premature births.
Menstrual history: Do you experience any of the following: PMS, heavy bleeding, pain during intercourse, etc.?
ContraceptionDo you use contraception? If yes, for how long?
**Rate your interest in sex: High, Moderate, Low, None **Have you experienced rape, trauma, or incest in the past? If yes, when?
Spinal Attunement
What are you seeking from this Spinal Attunement session?
Do you have any current emotional stressors / traumas that you feel you are moving through?If yes please elaborate on; the situation, the emotion/trauma and whether this is being managed
Do you have any past emotional stressors / traumas that you feel you are still processing / still think about?If yes please elaborate on; the situation, the emotion/trauma and whether this is being managed
How would you rate your daily energy level?

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Stress
What do you do for work?
Do you enjoy what you do?
Are there any other stress in your life?
Rate your overall stress level

1

2

3

4

5

1 is Lowest, 5 is Highest
General Complains
Do you have any emotional complaints? If yes, please describe.
Do you have any physical complaints? If yes, please describe.
Do you have any mental complaints? If yes, please describe.
Do you have any energetic complaints? If yes, please describe.
Do you have any spiritual complaints? If yes, please describe.
Do you have any complaints related to your childhood? If yes, please describe.
Do you have any complaints in your relationships? If yes, please describe.
Since when have you been experiencing these complaints?
Have you ever been treated by a general practitioner, specialist, or psychiatrist for these complaints? If yes, what was the outcome of the treatment?
Agreements
I UNDERSTAND THAT THIS IS A DRUG AND ALCOHOL FREE SESSION (this includes in the 12 hours leading up to the session, not just the session time itself) This question is required.

I acceptI do not accept
I acknowledge that these processes may bring up deep emotional release, physical tensions and traumas. I acknowledge that I am consenting to this process and knowing this, am responsible for my choice to enter this experience

I acceptI do not accept
I understand that this session is powerful and I acknowledge the importance to clear my schedule of busyness so that there is space for healing & integration to take place after the session

I acceptI do not accept
I acknowledge that the therapy activities in which I will engage as part of the treatment provided by Keren Cogan / Lucien Nabbs have risks. By my participation in the therapy, I hereby assume all risks and all responsibility for any loss or damage.I voluntarily agree to release, waive, discharge, hold harmless, defend, and indemnify Keren Cogan/ Lucien Nabbs from any and all claims, actions or losses which may arise out of the therapy. I agree to cooperate fully, to participate in all therapy procedures, and to comply with the plan of care as it is established. If I have any medical conditions, I have consulted with my physician to make sure that physical therapy is appropriate for me to participate in.

I acceptI do not accept
Thank You!I am looking forwards to our Immersion together
Should be Empty:

Health Survey

Medical

Womb Health

Spinal Attunement

Stress

General Complains

Agreements