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?
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?
Are you currently under a physician’s care for any condition?
If yes, please describe:

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