Client Intake Form First Name Last Name Email Phone Number Age Gender FemaleMalePrefer Not To SayI'll let you know my preferred pronoun Location KerrisdaleWest Vancouver108 Mile Ranch Occupation What physical activities do you take part in regularly? Referred by Have you had previous bodywork experience? Yes No Main Concerns and Symptoms: Pain Pattern: ConstantOn/Off Do you have any other concerns? Do you frequently experience a high level of stress? YesNoUnsure Do you experience numbness, tingling or weakness in extremities? YesNo Do you have any previous injuries, scars or have had any surgeries? Are you on any medication? Have you ever experienced any of the following? Check all that apply. Acute Stroke Cerebral Aneurysm Hemorrhage Herniated medulla Oblongata Recent Skull Fracture Cerebrospinal Fluid Leak Spina Bifida Arnold Chiari Malformation Increased Intracranial Pressure Whiplash Headaches Vision Problems Breast Implants Broken Bones Scars Grinding Teeth Dental Issues Respiratory Problems Digestive Issues Trauma Giving Birth Own Birth Trauma Tinnitus Sinus Problems Irritable Bowel Syndrome Acid Reflux Are you currently pregnant? YesNo Any other past or present illnesses I should know about? Any additional thoughts or concerns? I have listed all my known medical conditions and physical limitations and I will inform my therapist of any changes in my health. I understand that a Craniosacral Therapist does not diagnose illness, disease or any other medical, physical or mental disorder. Agree Send
