Name *

First Name

Last Name

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Birth Date *

MM

DD

YYYY

Emergency Contact Phone *

(###)

###

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Have you previously experienced CranioSacral Therapy?

Yes

No

Are you currently under a physician’s care for any condition? *

Yes

No

Physician’s Fax

(###)

###

####

Do you wear contact lenses?

Yes

No

Do you wear dentures?

Yes

No

Have you had extensive dental work (ie; braces, etc.)?

Yes

No

Car accident (at any time), serious falls or injuries?

Yes

No

Do you have any allergies?

Yes

No

Do you have arthritis? What type and where?

Yes

No

Do you have any heart problems?

Yes

No

Do you have any spinal problems?

Yes

No

Are you presently pregnant? How far along? Complications?

Yes

No

Have you had surgery? How recently? Complications?

Yes

No

Do you take any prescribed medications?

Yes

No

Do you exercise or play sports on a regular basis?

Yes

No

Are you receiving any other complementary care currently, (chiropractor, naturopathic, acupuncture, nutritional, herbal, homeopathic, hypnotherapy)?

Yes

No

Do you have any other physical or mental condition of which I should be aware before giving you a CranioSacral session?

Yes

No

*

I understand that the CranioSacral therapist does not diagnose illness, disease, or any other physical or mental disorder. In addition, the CranioSacral therapist does not prescribe medical treatment or pharmaceuticals.

*

I understand that craniosacral therapy is considered to be a contraindication for recent injuries to the head and neck, ie; recent whiplash, any recent fracture to base of the neck, concussion, hemmorage, as well as rheumatoid arthritis, and state that I am not currently experiencing any of these conditions.

*

It has been made very clear to me that cranioSacral therapy is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.

*

Because a CranioSacral therapist must be aware of existing physical conditions, I have stated all my known medical conditions and take it upon myself to keep the CranioSacral therapist updated on my physical health. Further, I release the therapist from responsibility and liability for any adverse reactions resulting from disclosed and undisclosed conditions.

Signature *

First Name

Last Name

Today's Date *

MM

DD

YYYY