Intake Questionaire is used to help clarify your goals and identify the origin of your health issue. Symptoms are helpful for me to know however I am looking to discover the original imbalances that may have occurred at an earlier time in your souls journey.

 

 

 

Name  

Date of Birth         

Address                                                      

Email………………………………

Tel#

                       

              

 

Who may we call in an emergency?_________________________________

                                           

         

 

What do you want to work on today?

 

 

When was your last physical?   

 

 

Do you have cardiac or circulation problems?

 

Any cramps?

 

Please review your accident history: auto, horse, trees, stairs, ice, snow?

 

Please mention any history of violence and trauma.

 

 

 

Any history of unconsciousness or concussion or seizures?

 

                                     

Have you strained or sprained ankles or broken any bones ?

 

 

Do you get headaches or migraines?  

         

On a scale of 1-10 how much pain are you in?______ How much stress?_______

 

Is any area numb or suffer from loss of feeling?

 

What type of exercise do you enjoy?

  

Does sleep restore your vitality?

 

Please list medication

 

Describe the use of alcohol and other substances for your self.

 

Discribe the history of family mental illness. 

 

Any family health concerns?

  

Is there anything else you should bring to my attention?

 

 

This appointment 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 polarity, biodynamic craniosacral or other bodywork therapies are provided for the purpose of stress reduction, relaxation and relief of inner or outer tension. If I experience any pain or discomfort during any session I will immediately inform the practitioner so that the hand pressure may be adjusted to the level of my comfort. I further understand that polarity, craniosacral or other bodywork 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 polarity, craniosacral or other bodywork therapy should not be done under certain medical conditions, I affirm that I have stated all my known medical conditions and answered all questions honestly. 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……

 

Signature.......................................................Date.....................

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

Practitioner....................................................Date....................

 

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