Client Information For Craniosacral Therapy Form printable pdf download

Client Information for CranioSacral Therapy

Date___/___/____

Name ____________________________________________________________________ Date of Birth ___/___/_____

Address________________________________________________ City __________________ State_______ Zip ______

Home Phone (____)____________________ Cell (____)____________________ Best number to call: ___ home ___ cell

Email: ________________________________________________ Referred by: _________________________________

In Case of Emergency _______________________________________________ Phone (____)______________________

Occupation __________________________________ Under Chiropractic Care ___ No ___ Yes How long? ____________

Please take a minute to carefully read the following information and sign where indicated. If you have a specific condition or specific

symptoms, CST/bodywork may be contraindicated. Do you (have)/Are you:

__Yes __No

suffering from stress?

__Yes __No

currently pregnant?

__Yes __No

any broken bones in the past?

__Yes __No

have children?

__Yes __No

frequent headaches?

__Yes __No

epilepsy or seizures?

__Yes __No

any accidents or injuries or traumas?

__Yes __No

arthritis?

__Yes __No

currently wearing contact lenses?

__Yes __No

high blood pressure?

__Yes __No

birth trauma/ assisted delivery?

__Yes __No

if yes to above, taking meds?

__Yes __No

back pain?

__Yes __No

heart or circulatory issues?

__Yes __No

joint swelling?

__Yes __No

varicose veins?

__Yes __No

a contagious disease?

__Yes __No

osteoporosis?

__Yes __No

any allergies?

__Yes __No

ever had surgery?

__Yes __No

whiplash?

List:____________________________________________

__Yes __No

bruise easily?

___________________________________________

__Yes __No

diabetes?

__Yes __No

Head Impacts/ Injuries?

__Yes __No

vertigo?

List: __________________________________________

Do you have areas of soreness, tension or sensitive to touch? If yes, explain:

__________________________________________________________________________________________________

Do you have numbness or stabbing pains anywhere? If yes, explain:

_________________________________________________________________________________________________

Do you have any other condition, or are taking any medications not mentioned above?

_________________________________________________________________________________________________

Comments:

_________________________________________________________________________________________________

I understand that the CST/bodywork I receive is provided for the purpose of relaxation, relief of muscular tension, general health

and wellbeing improvements. If I experience any pain or discomfort during this session or any future sessions, I will immediately

inform the practitioner so that the pressure and/or positioning may be adjusted to my level of comfort. I further understand that

bodywork should not be construed as a substitute for medical examination, diagnosis or treatment and that I should see a physician,

chiropractor or other qualified specialist for any mental or physical ailment of which I am aware. I understand that CST/bodywork

practitioners do not preform spinal or skeletal adjustments, diagnose, prescribe or treat any physical or mental illness, and that

nothing said in the course of the session given shall be construed as such. Because bodywork should not be performed under certain

health conditions, I affirm that I have stated all my known health conditions and answered all questions honestly. I agree to keep the

practitioner updated with any changes to my health profile and understand that there shall be no liability on the practitioner’s part

should I fail to do so. I understand that any illicit or sexually suggestive remarks or advances made by me will result in immediate

termination of the session, and I will be liable for payment of the scheduled appointment.

Client Signature: _________________________________________________________________________ Date ____/____/____

Client Information For Craniosacral Therapy Form

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