Welcome to Healthcare And Wholeness-Bio Dynamic Cranio Sacral Therapy

New Patient Form

Please fill up the form or click here to download.

Name: Date of Initial Visit:
Address:
Home Phone: Work Phone:
Date of Birth: Age: Occupation:
Marital status: Referred by:
Have you had biodynamic cranio-sacral treatment before?:
When?: What was your experience?:
Have you had trauma treatment before?:
What type?: .

REASON FOR YOUR VISIT:

What is your primary concern?:
What are other areas of concern?:
When did your first notice it?:
What brought it on?:
Describe any stressors occurring at the time?:
What activities provide relief?: What makes it worse?:
Is this condition getting worse?: interfere with work?:
Sleep: recreation:
Describe your exercise routine (type, frequency):
How much water do you drink in a day (in litres )?:

FAMILY HISTORY:

Alive ? Age/Cause of Death Major Health lssues

Mother: Father:
Siblings birth order:

MEDICAL HISTORY

Are you currently under the care of another health care provider(s)?:
Reason (s):
Name(s) of Medical Doctor?:
Address:
Phone: email:
Current Medications:
Allergies: specify allergen and reaction:
Supplements/Remedies:
Surgical History (year and type):
Recent Procedures:
Hospitalizations:
Accidents or Traumas:
Falls/Injuries: Birth:

Circle any of the following you are currently experiencing and Underline any of the following you have experienced in the Past.

Headaches(migraine), tension, cluster Ringing in Ears Pins and needles in arms, legs, hands or feet

Asthma Cold Hands or Feet Swollen ankles Sinus Conditions Seizures Loss of Smell or Taste Skin Disorders:Acne, Fungus, Psoriasis

Sciatica Painful Joints Swollen Joints Spinal Problems Anxiety Fatigue

Trouble Sleeping Fainting Spells Loss of Memory Depression

Muscular Tightness:(location): Varicose Veins (location):
Herniated or Bulging disc:(location): High or Low Blood Pressure:

Contact lenses Dentures Artificial /Missing limbs Frequent Colds/Upper Respiratory conditions

Digestive Problems:
Inability or Frequent Urination:
Other:

Please read and sign:

I understand that payment is due at the time of treatment unless arrangements have been made other wise.

I agree to give at least 24 hours notice of cancellation of appointment otherwise full session fee will be owed. Cases of emergency are considered exceptions to this cancellation policy.

I understand the treatment here is not a replacement for my current medical care.

I understand the therapist/practitioner does not diagnose medical illness, disease or any other physical or mental conditions (unless specified under his/her professional scope of practice)

As such, the therapist/practitioner does not prescribe allopathic drugs or medical treatments or medication nor does he/she perform any spinal manipulations (unless specified under his/her professional scope of practice)

I understand that the treatment is not a substitute for medical treatments and/or diagnosis and it is recommended that I see a qualified professional for any physical or mental conditions that I may have.

I have stated all my known conditions and take it upon myself to keep the therapist/practitioner updated on my health.

Patient’ s signature: Date:
Therapist/practitioner Signature: Date:

Patient Confidentiality Release Form

I,(client name):
Address:
Phone: Email:

give my permission, for my practitioner, Ashwini Mehta, CST to take notes about me, including health history / medical and/ or personal information I choose to disclose to her. I am aware that my practitioner may use this information to provide me with a summary for my own personal use.

Signature: Date:

Confidentiality Release in case another Medical doctor, practitioner, family member or individual is involved.

I,(patient name)

give Ashwini Mehta, CST, my practitioner, my permission to discuss my medical details including current condition and health history with my Medical Physician / Mental Health care Professional / Parents: Father / Mother / Spouse

(name or names of Individuals).

Date: