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Biodynamic Craniosacral Therapy
Deep Tissue
Parasympathetic / Swedish
Intake Form
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Intake Form
Patient Information:
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Address
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Armed Forces Americas
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State
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Date of Birth
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Primary Health care provider
Emergency Contact
Relationship
Who referred you?
Cause of Injury or Concern:
Primary
Onset Date
MM slash DD slash YYYY
Please rate your injury
Mild
Moderate
Disabling
How often are your symptoms present?
Secondary
Onset Date
MM slash DD slash YYYY
Please rate your injury
Mild
Moderate
Disabling
How often are your symptoms present?
What treatments have you received?
Are you being treated by a doctor for these or any condition?
What medications or supplements do you take?
Rate your stress level
Mild
Moderate
High
How are your conditions affecting your daily life?
Are you currently facing any life circumstances that are stressful for you?
What are your aspirations for treatment?
Would you like to share any information about your early life or family that feels relevant to your healing process?
Have you had any life experiences that you feel you could use support in processing through your nervous system (physical or emotional trauma or injuries)?
What in life supports your wellbeing?
Existing Conditions Information:
Please list any surgeries, injuries, major illnesses and associated dates:
Neurological, Head and Neck
Concussion
Hearing loss
Epilepsy
Migraines
Issues with vision
Parkinsons
Headaches
Memory Issues
Cerebral Palsy
Brain injury
TMJ/Jaw pain
Seizures
Dizziness/Vertigo
Sinus Issues
Herniated disc
C/PTSD
Tingling, numbness, burning or stabbing sensations
Cardiovascular
Cold hands, feet
Asthma
Stroke (CVA)
High or low blood pressure
Shortness of breath
Heart disease
Lymphedema
Myocardial Infarction
Empthysema
Aneurysm
Arrhythmia
Pacemaker
Soft tissue and joints
Feet
Low back
Arms
Sprains, strains
Ankles
Mid back
Hands
Tendonitis
Legs
Upper back
Neck
Stiff or painful joints
Knees
Shoulders
Weak or sore muscles
Other conditons
Insomnia
Depression
Anaphylaxis
Infectious skin condition
Anxiety
Diabetes
Digestive conditions
Arthritis
Allergies
Cancer
Other medical condition
Fatigue
Hemophilia
Auto-immune condition
Please list any other conditions I should be aware of:
Name
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