Richard is a memeber of the following associations

Biodynamic Craniosacral Therapy Association

https://www.craniosacraltherapy.org/

Bodywork and Massage Practitioners  

www.abmp.com

The International Polarity Alliance

www.polarityeducation.org

Only working in person with family, friends and former bodywork clients

Medical History for Bodywork 

Date of Birth

Name

Address

Telephone              

Emergency contact name and number                  

What do you want to work on?

Any health concerns? 

Any cardiac or circulation problems?

Were you adopted ?

Have you ever had a concussion,

seizure,

stroke

Describe your

headaches,

and migraines 

Any accidents sports or car?

What is your level of physical pain 1-10

What is your level of emotional pain 1-10

Any loss of memory?

Any mental health hospitalization (s)?

Briefly describe your trauma(s)

Does sleep restore your vitality?        

Current medications?

How much water/fluids do you drink daily?

Tell me about your diet?

Do you use alcohol, cannabis or street drugs, please describe

Is there anything else you should bring to my attention?

This is your time for establishing and improving the health of your mind, body and spirit.

If you need to reschedule a minimum 24 hours cancellation notice from you is important,

because someone else may want this time.  Please initial………..

I understand that in-person craniosacral, polarity or non-local energy therapies are provided for the

purpose of stress reduction, relaxation and relief of inner or outer tension. If you

experience any pain or discomfort during any session you will immediately inform the

practitioner so that the hand pressure or distance from you may be adjusted to the

level of your comfort. I further understand that craniosacral, polarity or

energy therapy should not be misconstrued as a substitute for medical

examination, diagnosis or treatment and that I should see a medical doctor,

naturopath, osteopath or other medical specialist for any mental or physical

ailment I am aware of. Please initial..............

Because craniosacral and polarity bodywork should not be done under certain medical

conditions, I affirm that I have stated all my known medical conditions and answered

all questions honestly. Please initial…………

I agree to keep the practitioner updated as to any changes in my medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so. 

Please Initial……

Your Signature……………………………..Date……………………….

Parent or Guardian…………………………Date……………………….

Practitioner: Richard Crandall