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Intake and Consent/Liability Forms PDF

 

Ortho-Bionomy® and Reiki Client Intake Form

Name ________________________________ Home Phone ______________Cell _______________

Address ____________________________________________________________________

City/State/Zip _____________________________________________________________

Email (optional) _________________________________ Date of Birth ___________

Occupation _______________________________________

Emergency Contact _______________________________________ Phone _______________

Are you currently seeing a Chiropractor, Physical Therapist, or Physician for an ongoing issue?

____ Yes    ____ No    Please Explain:

________________________________________________________________________

________________________________________________________________________

May I have permission to consult with your physician if necessary? Please initial if yes.

____Yes   ____No

PERSONAL STRESSORS AND EMOTIONAL STATE

Please circle your current stress level:     Low    1 2 3 4 5    High

Typically, where do you hold stress? ______________________________________________

What type of sleep do you normally have? _________________________________________

Do you take recreational drugs? ____ Yes    ____ No

BRIEF DESCRIPTION OF PHYSICAL COMPLAINT AND CIRCLE THE LOCATION OF THE PROBLEM ON THE BODY BELOW

human body 4l views

____________________________________________________________

____________________________________________________________

____________________________________________________________

____________________________________________________________

Have you had a recent major surgical procedure or injury? ____ Yes    ____ No

Please Explain: ______________________________________________________________

______________________________________________________________________________

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