Wellness Questionnaire for Cranial Sacral Treatment

To submit this form by email, copy and paste it into an email and submit it electronically.  To fill out a hard copy, you may print out a Wellness Questionnaire for Cranial Sacral Therapy and bring it with you to your appointment.

How did you hear about Living Room Yoga?

1.  Name:

2.  Address:

 

3.  Phone:                                                                                       

4,  Alternative Phone:

5.  Email:                                                                                                    6.  Do you receive our E-Newsletter?     

7.  Birth Date:

8.  Name and phone number of healthcare provider:

 

9.  Medications you are on and what they are for:

 

10.  What is your experience with cranial sacral therapy?

 

11.  What major surgeries have you had?

 

12.  List any accidents or injuries with approximate dates:

 

13.   Please check any of the following symptoms you experience.  If you are answering this electronically by email, please delete the symptoms you do not have under each category.  You will notice that some symptoms appear more than once.  Choose the symptoms you have each time they appear (under each category) as this will guide your treatment.

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