Osiana Wellness - Client Information Form

Address *

Phone Number (best way to reach you) *

Area Code Phone Number
Which number is this? *
Age
Your Birthday *

Month Day Year Date Picker Icon
Occupation / Retired / Student / Other: *
Emergency Contact Person: *
Emergency Contact Phone Number *

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

Craniosacral Therapy ThetaHealing Neither
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? *

Yes No
Are you currently under a physician’s care for any condition? *

Yes No
If yes, please describe:

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

Yes No
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 lenses Wear dentures Have 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.
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Client Information Form