Osiana Wellness - Client Information Form

www.osianawellness.com

osianamontanita@gmail.com | 819-230-0826
Client Information Form
Name*

First NameLast Name
Email*
Address*

Street Address

Street Address 2

City/TownProvince

Postal Code
Phone Number (best way to reach you)*

Area CodePhone Number
Which number is this?*
Age
Your Birthday*

MonthDayYear
Occupation / Retired / Student / Other:*
Emergency Contact Person:*
Emergency Contact Phone Number*

Area CodePhone Number
Have you had Craniosacral Therapy / ThetaHealing before?*

Craniosacral TherapyThetaHealingNeither
How did you find out about Osiana Wellness? (if referred, please note the name of the person) *
Would you like to receive a monthly e-newsletter on specials, events or updates?*

YesNo
Are you currently under a physician’s care for any condition?*

YesNo
If yes, please describe:

0/50
Are you receiving any other complementary care currently (chiropractor, naturopathic, acupuncture, massage, nutritional, homeopathic,osteopathy, other)?*

YesNo
If yes, please describe:

0/50
Primary reason for your visit, (please explain):*

0/50
Main area of complaint - pain, tension, digestive, emotional, mental, etc. (please explain): *

0/50
In a few words, please describe your goal for this session: *

0/50
Have you suffered any form of trauma your body may be holding? (death, accidents, abuse, etc.) *

0/50
Are you aware of any trauma along your family lines? *

0/50
Lifestyle

Please rate the following on a scale of 1 (healthy) to 5 (troublesome):*

Please rate how often you consume the following on a scale of 1 (never) to 5 (daily):*

What tools, practices and activities do you use to relieve stress and maintain your well-being?*

0/50

For the remaining questions, please check and describe only the ones that apply to you:
Which of the following applies to you?

Wear contact lensesWear denturesHave had extensive dental work (i.e. braces, etc.)
Describe any car accidents (at any time), serious falls or injuries:

0/50
Allergies/sensitivities – Please describe allergens:

0/50
Arthritis - What type and where:

0/50
Heart problem - Please describe:

0/50
Spinal problems – Please describe:

0/50
Presently pregnant - How far along? Complications?

0/50
Have had surgery - When? Complications?

0/50
Taking prescribed medications - Please list:

0/50
Exercise or play sports on a regular basis - Please describe:

0/50
Any other physical, mental or emotional conditions of which I should be aware before giving you a session. Please describe:

0/50
NOTE: *Craniosacral Therapy is considered to be a contraindication for recent fractures to the base of the skull and neck. Please notify Osiana Wellness if you recently experienced this or any other injuries.
Enter the message as it's shown*
Should be Empty:

Client Information Form