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Home
About Hazel
Reflections
Cranio Sessions
What is Biodynamic Craniosacral Therapy?
Book a Session
Free Consultation
Yoga
Yoga Classes
Yoga Therapy
Book a Session
Free Consultation
Testimonials
Intake Form
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2023-11-22T19:20:26+00:00
Client Intake Form
Full name
*
Email Address
*
Phone
*
Town
Date of birth
dd/mm/yyyy
Referred by
Please list any major accidents or medical interventions/surgeries (including dates if possible)
Please list any major emotionally stressful/ traumatic events (including dates if possible) and support you have received
Please list current medications you are taking if any & the conditions they are treating
Is there anything you would like to mention about your Family Medical History
major illnesses, long term conditions, or health issues, or anything unusual for the following family members: For example, Mother, Father, Grandparents, siblings etc.
Is there anything you would like to mention about your Pregnancy history
Number of pregnancies and births with dates. Were there any complications/ miscarriages/ terminations? If currently pregnant, how many weeks?
Please tick any of the following which you may have issues with either recently or in the past.
Head and Neck
Headaches / migraines
Ringing in ears
Vision problems
Vertigo / dizziness
Hearing loss
Vision loss
Whiplash
Root canal/ tooth implant
Thyroid conditions
Nervous system
Sensory loss / change
Numbness / tingling
Sciatica
Epilepsy
Seizures
Multiple sclerosis
Stress
Skin and infections
Hepatitis
HIV / AIDS
Herpes
Tuberculosis
Lyme disease
Infectious skin conditions
Scars/ tattoo
Musculoskeletal
Arthritis
Osteoporosis
Tendonitis
Bursitis
Jaw pain (TMJ)
Pins / plates / wires / artificial joint
Physical injury
Cardiovascular
High blood pressure
Low blood pressure
Heart attack
Stroke
Heart disease
Poor circulation
Anaemia
Phlebitis / varicose veins
Respiratory
Asthma
Shortness of breath
Chronic cough
Bronchitis
Emphysema
Sinusitis
Frequent colds
Smoker
Emotional/ mental
Bereavement
Depression
Anxiety
Difficulty with concentration
Psychiatric disorder
Other conditions
Cancer
Diabetes
Reproductive conditions
Unexplained weight loss
Digestive conditions
Fibromyalgia
Chronic fatigue syndrome
Autoimmune disease
Any other health challenges or details on the above?
Have you experienced Craniosacral Therapy previously?
Yes
No
Have you got any concerns with getting a B-CST session?
Yes
No
Please give more information
Date of last treatment/ name of practitioner/ list your concerns here
Reason for initial visit?
*
Consent
*
I understand that Biodynamic CranioSacral therapy (B-CST) is a profound, yet gentle hands-on modality that works with the subtle rhythm of the cerebrospinal fluid in the body and is used for stress reduction and relaxation which precede healing process. It gives support and encourages body's systems to reestablish balance physically, mentally and emotionally.
BCST has been shown to be effective in treating a wide range of physiological issues associated with pain and loss of biomechanical, systemic and emotional function/wellbeing.
I understand that B-CST can complement any medical or psychological care I may be receiving. I understand that B-CST does not take the place of medical care.
I acknowledge that long term imbalances in the body sometimes require multiple sessions in order to facilitate the level of relaxation needed by the body to heal.
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