First Time Patient Form Name * First Name Last Name Date of Birth MM DD YYYY Email * Mobile Phone * (###) ### #### Work Phone (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Referred by Emergency Contact * Emergency Contact Relationship * Emergency Phone * (###) ### #### How would you rate your general health? Excellent Fair Good Poor List current medications & the conditions they are treating Please tell us about any allergies or hypersensitivities Physician's Name Physician's Phone (###) ### #### Occupation Are you experiencing any symptoms from your job? Have you experienced CranioSacral Therapy before? Yes No If yes, please list the date of last treatment MM DD YYYY List any major accidents or surgeries (including dates) Reason for initial visit Head Neck Headaches/migranes Ringing in ears Vision problems Vertigo/dizziness Hearing loss Vision loss Respiratory Asthma Chronic cough Emphysema Frequent colds Family history of respiratory difficulties Shortness of breath Bronchitis Sinusitis Smoker Nervous System Sensory loss/change Sciatica Seizures Numbness/tingling Epilepsy Multiple sclerosis Musculoskeletal System Arthritis Osteoporosis Bursitis Family history of arthritis Jaw pain (TMJ) Pins/plates/wires/artificial joint Reproductive Pregnant Given birth Gynecological problems Cardiovascular High blood pressure Heart attack Heart disease Phlebitis/varicose veins Hemophilia Chronic congestive heart failure Low blood pressure Stroke Poor circulation Pacemaker Family history of cardiovascular problems Skin & Infections Hepatitis Herpes Lyme disease HIV/Aids Tuberculosis Infectious skin conditions Other Condtions Cancer Diabetes Unexplained weight loss Fibromyalgia Depression Digestive conditions Chronic fatigue syndrome Anxiety Psychiatric disorder Other Conditions (not otherwise mentioned) Consent * It is my choice to receive CranioSacral Therapy. I am aware of the benefits and risks of CranioSacral Therapy and give my consent for CranioSacral Therapy. I understand that there is no implied or stated guarantee of success of effectiveness of individual techniques or series of appointments. I acknowledge that CranioSacral Therapy is not a substitute for medical care, medical examination or diagnosis. I have stated all medical conditions that I am aware of and will inform my practitioner of any changes in my health status. I understand that my personal health information will be collected. I understand that all information that I provide will be kept confidential unless required by law. I understand and consent that my medical information may be shared by the various care providers involved in my care and treatment. I consent by checking this box in lieu of my signature I do not consent by checking this box in lieu of my signature Thank you! Your first-time client form has been received by Breathe Wellness.
