Pediatric Craniosacral Therapy/Myofascial Unwinding Client Intake Form

Client (Baby or Child)

Date of birth

Address*

Select Country*

Select State*

Address Line 1* Address Line 2

City*

Zip Code*

Father/Mother

Phone

E-mail

Mother/Father

Phone

E-mail

Siblings: Please list names, and ages.

Who may I thank for referring you?

Family Medical History

Please indicate if any blood relatives to the child have had any of the following by using the notations: M = Mother MGM = Maternal Grandmother PGM = Paternal Grandmother F = Father MGF = Maternal Grandfather PGF = Paternal Grandfather S = Sibling

Allergy, Asthma or Eczema

Cancer

Diabetes or Low Blood Surgar

Heart Trouble

High Blood Pressure/Stroke

Kidney Disease

Liver Disease

Developmental Disability

Mental Illnesses

Scoliosis

Ulcer

Seizure Disorder

Vaccine Reaction

Other, Please Explain:

Pregnancy

Please check any areas that applied to the client's mother during her pregnancy:*

Prenatal Classes
Premature Contractions
Complications
Back Pain
Bleeding
Other Pain
Hospitalization
Smoking
Alcohol
Recreational Drugs
Excessive Weight Loss
Excessive Weight Gain
Medications
Toxic Exposures
Caffeine: Cola/Pop
Caffeine: Coffee
Caffeine: Tea
Caffeine: Chocolate
Caffeine: Other
Immunizations/Flu Shot
Allergic Reactions
Mental Trauma
Vitamins/Minerals
Chiropractic Care
Any Diagnosed Illnesses
Attitude Mostly Happy
Attitude Mostly Depressed
Any Physical Injury

Birthing Time and Birth (Labor and Delivery)

Please check any item(s) that apply:*

Homebirth
Hospital Birth
Induction
Caesarean
Complications
Continuous Fetal Monitor Used
Intermittent Monitoring Used
Premature Delivery
Vacuum Extraction
Forceps Used
Other: Please explain below

Please explain more here:

Birth Information

Please check any item(s) that applied to the baby/child at birth*

Difficulty Breathing
Choking
Crying
Sleeping Excessively
Difficulty Walking/Lethargic
Jaundice
Coloring
Difficulty Latching on
Difficulty Breastfeeding
Medications
Surgery
Circumcision
Formula Feeding
Vitamin K
Erythromycin
Other: Please explain below

Please explain here

Length of Pregnancy

Birth Weight

Birth Length

Head Circumference:

Apgar Score at 1 minute:

Apgar Score at 5 minutes:

Nutrition

Please indicate if the baby/child has received any of the following:*

Breastmilk
Commercial Formula
Cow's Milk
Goat's Milk
Other Milk:
Juice: Fruit
Juice: Vegetable
Solid Foods
Vegetarian Diet
Organic Meats
Vitamins
Sweets/Candy
Medications

Other: Please explain

Vaccinations/Immunizations

Please list if the baby/child has had any vaccination (immunizations) reactions (minimal response to severe): List date, type, and their response*

Has the baby/child traveled abroad? Where? When?

Illnesses

Please list an illnesses or previously diagnosed conditions:*

Health Care Providers

Pediatrician

Practice Name

Date of last visit

Midwifes name

Practice Name

Date of last visit

Chiropractor

Practices Name

Date of last visit

Occupational therapists

Practices Name

Date of last visit

General System Review

Please check any that apply to baby/child:

Had any allergies, eczema, hay fever, hives, asthma or drug reactions?
Been unconscious or had a convulsion?
Had problems with the eyes, including vision?
Been cyanotic (turned blue)?
Had recurring problems with vomiting, diarrhea, constipation or stomach pain?
Had problems passing stools?
Had unusual stools in appearance or smell?
Had problems passing urine?
Had unusual urine in appearance or smell?
Complain of any extremity or back pain?
Do you notice a limp or unusual gait pattern?
Tolerated exercise?
Had any other problems?

Please take a moment to carefully read the following information and sign where indicated. If your child has a specific medical condition or specific symptoms, craniosacral therapy may be contraindicated. A referral from your primary care provider may be required prior to service being provided. I understand that the craniosacral therapy that my child receives is provided for the basic purpose of relaxation and relief of muscular/connective tissue tension. If I notice that my child is experiencing any pain or discomfort during this session, I will immediately inform the practitioner so that the pressure and/or strokes may be adjusted to my child’s level of comfort. I further understand that craniosacral therapy should not be construed as a substitute for medical examination, diagnosis, or treatment and that I should see a physician, chiropractor or other qualified medical specialist for any mental or physical ailments that I am aware of. I understand that craniosacral therapy practitioners are not qualified to perform spinal or skeletal adjustments, diagnose, prescribe, or treat any physical or mental illness, and that nothing said in the course of the session given should be construed as such. Because craniosacral therapy should not be performed under certain medical conditions, I affirm that I have stated all my child’s known medical conditions and answered all questions honestly. I agree to keep the practitioner updated as to any changes in my child’s medical profile and understand that there shall be no liability on the practitioner’s part should I forget to do so;

If I make any sexual advancements or innuendos the session will be terminated immediately without a refund.

I agree to give 48-Hour notice if I choose to reschedule or cancel an appointment for any reason other than a family emergency or sudden illness. If I cancel without 48-hour notice or do not show up to my appointment I agree to pay the full cost of the craniosacral therapy session.

By submitting this form I affirm the accuracy of the information I have provided and understand and agree to the policies above.

I have read and agree with the above statements*

Signature*