Client Information Form - CranioSacral Therapy

CONFIDENTIALITY: All information on this questionnaire will be kept strictly confidential. 

Name *
Address *
Phone *
Birth Date *
Birth Date
Emergency Contact Phone *
Emergency Contact Phone
Have you previously experienced CranioSacral Therapy?
Are you currently under a physician’s care for any condition? *
Physician’s Fax
Physician’s Fax
Please answer the following questions:
Do you wear contact lenses?
Do you wear dentures?
Have you had extensive dental work (ie; braces, etc.)?
Car accident (at any time), serious falls or injuries?
Do you have any allergies?
Do you have arthritis? What type and where?
Do you have any heart problems?
Do you have any spinal problems?
Are you presently pregnant? How far along? Complications?
Have you had surgery? How recently? Complications?
Do you take any prescribed medications?
Do you exercise or play sports on a regular basis?
Are you receiving any other complementary care currently, (chiropractor, naturopathic, acupuncture, nutritional, herbal, homeopathic, hypnotherapy)?
Do you have any other physical or mental condition of which I should be aware before giving you a CranioSacral session?
Please read and mark the boxes below
By typing my name below acknowledge I have completed the above information accurately and have read, understand, and take responsibility for the above statements.
Signature *
Today's Date *
Today's Date