Intake Form
Name:____________________________________Birth Date:_________________
Address:_____________________________________________________________
Phone: Home:_______________ Cell:___________________ Work:__________________
Name and phone number of emergency contact person:______________________________
Name and phone number of physician/primary HCP:________________________________
Are you currently pregnant?_______________
What illnesses, injuries or surgeries have you had in the past 2 years?__________________
Do you currently have any medical condition that might be affected by slight increases in intracranial pressure? Stroke, skull fracture, concussion, aneurysm, etc?_________________
Have you had other significant injuries or illnesses previously?________________________
Head injury? Seizures? Tailbone fall? Orthodontia or major dental work? Serious car accident?
Was your birth traumatic or complicated?________________________________
Are you taking any medicines, vitamins, herbal or homeopathic treatments?______________
What changes in your body/health/well being are you hoping for?_____________________
Patient/Practitioner Agreement:
I understand that massage/bodywork/craniosacral therapy (CST) should not be a substitute for a medical examination, diagnosis, or treatment and I should see a qualified medical specialist for any mental or physical ailment that may be present. I understand that massage therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness. I agree that it is my responsibility to keep the practitioner notified of any and all changes to my medical condition.
I also accept the possibility that my body is wise and often capable of healing itself. Following a session I may experience temporary sensations, which are unique to my healing process. I understand that I am encouraged to contact my therapist to ask about anything that concerns me at any time.
Name:____________________________________________ Date:_________________
Practitioner:_________________________________________Date:_________________
