Bowen Therapy New Client Form printable pdf download

BOWEN THERAPY NEW CLIENT FORM

Personal Information:

Name:

________________________________________________________________________

Phone (day): _____________________ Mobile: ____________________________________________

Address:

___________________________________________________________________________________

Email: _____________________________________________________________________________

Preferred appointment confirmation: mobile

work

home

Date of Birth: ____________________ Occupation: _________________________________________

Marital Status:

Number of Children: ______________________________________

Emergency Contact Name & Phone: ___________________________________________________

Relation: ___________________________________________________________________________

Private Health Insurance: ______________________ Member number: __________________________

I have been recommended by: __________________________________________________________

The following information will be used to help plan safe and effective bowen sessions. Please

answer the questions to the best of your knowledge.

Date of Initial Visit: _________________________________________________________________

1. FEMALE ONLY: Are you pregnant? Yes No

If yes, how far along are you? ________________________________________

2. Do you have any difficulty lying on your front, back, or side? Yes No

If yes, please explain: _______________________________________________________________

3. Do you sit for long hours at a workstation, computer, or driving? Yes No

If yes, please describe: ______________________________________________________________

4. Do you perform any repetitive movement in your work, sports, or hobby? Yes No

If yes, please describe: ______________________________________________________________

5. Do you experience stress in your work, family, or other aspect of your life? Yes No

If yes, how do you think it has affected your health?

muscle tension ( ) anxiety ( ) insomnia ( ) irritability ( ) other

6. Is there a particular area of the body where you are experiencing tension, stiffness, pain

or other discomfort? Yes No

If yes, please identify: ____________________________________________________

Bowen Therapy New Client Form