All information is strictly confidential.
First Name*
Last Name*
Preferred Name (if different)
Date of Birth*
Street Address*
City, State*
Zip Code*
Mailing Address (if different)
Email Address*
Best Phone Number*
Ok to text?* YesNo
If younger than age 18, name of parent/guardian:
Gender assigned at birth* MaleFemale
Current gender identity if different than birth
Please check your preferred session days and times, we’ll text you back with availability soon.
Thursday: Preferred Times (select all that apply)9:00am10:30amNoon1:30pm3:00pm5:30pm7:00pm Friday: Preferred Times (select all that apply)9:00am10:30amNoon1:30pm3:00pm5:30pm7:00pm Saturday: Preferred Times (select all that apply)9:00am10:30amNoon1:30pm3:00pm5:30pm7:00pm Sunday: Preferred Times (select all that apply)9:00am10:30amNoon1:30pm3:00pm5:30pm7:00pm
I have received CranioSacral and/or other types of osteopathic techniques.* YesNo I am able to walk up and down one flight of stairs.* YesNo
Diagnosis, Illness, or Injury
Approximate Date of Onset
Date of Diagnosis
Medication (Name, Dose)
Health Issue
Approx. Date of Onset
Type of Surgery
Date of Surgery
Any Complications
Device or Implant
Procedure & Body Location
Date of Procedure
Bone, Joint, Fascia, Muscle, Ligament, Tendon Issues (check any that have issues)
Please scroll down to see all physical area categories before checking where you have issues, and be sure to click the “complete” button before moving onto Symptoms. If you’re unsure which category for your issue, just do the best you can.
HEAD Top of Head Side of Head LeftRight Back of Head Forehead Temporal Eyebrow LeftRight Eye LeftRight Ear LeftRight Cheek LeftRight Mouth Jaw LeftRight Chin
NECK Front / Back FrontBack Left / Right LeftRight Spine
SHOULDERS LeftRight
TORSO Chest LeftRightMid Abdomen LeftRightMiddle Pelvis LeftRightMiddle
ARMS Upper Arm LeftRight Lower Arm LeftRight Hand LeftRight
Left Fingers ThumbPointerMiddleRingPinky Right Fingers ThumbPointerMiddleRingPinky
BACK Upper Back LeftRightSpine Spine LeftRightSpine Lower Back LeftRightMiddle
HIP & BUTTOCK Hip LeftRight Buttock LeftRight
LEGS Upper Leg LeftRight Knee LeftRight Lower Leg LeftRight Ankle LeftRight
FEET Feet LeftRight Left Toes Big Toe2nd Toe3rd Toe4th ToePinky Right Toes Big Toe2nd Toe3rd Toe4th ToePinky
HeadNeckShouldersUpper ArmsLower ArmsHandsFingersChestUpper BackAbdomenMid-BackPelvis/HipLower BackButtocksUpper LegsKneesLower LegsAnklesFeetToes
DIGESTIVE TeethTongueSalivary GlandsEsophagusStomachLiverGallbladderPancreasSmall IntestineLarge IntestineRectumAnus
RESPIRATORY NoseMouthSinusesPharynxLarynxTracheaBronchiLungsThoracic Diaphragm
URINARY Kidney(s)Ureter(s)BladderUrethra
INTEGUMENTARY SkinHairFatNails Exocrine Glands Sebaceous – skin Mucus – lining of tracts Tracts RespiratoryDigestiveUrogenital Ceruminous – ear Lacrimal – eye
ENDOCRINE GLANDS HypothalamusPituitaryPinealThyroidThymusParathyroidAdrenal(s)Ovary(s)Testicle(s)
IMMUNE / LYMPHATIC SkinBone Marrow Lymphatic Lymphatic VesselsLymph NodesSpleen Mucous Membranes Tonsils and Appendix
REPRODUCTIVE Female Ovary(s)Fallopian tube(s)UterusVaginaVulva Male PenisTesticle(s)Vasa DeferentiaSeminal vesicle(s)Prostate Physiological / Hormonal PhysiologicalHormonal
Please click "Body Area Completed" button before proceeding.
Your Body Area information is populated below when “Body Area Completed” button is clicked. If you have more than one symptom in a body area, or you need to add a Body Area not already listed, click on ADD SYMPTOM ROW.
Body Area
Specific Part
Symptom
Severity
—Please choose an option—Select...MildModerateSevere
Rate your current level of mental stress: mild, moderate, severe, and the duration of this level of stress.
Current Stress Level * MildModerateSevere
Duration of this level of stress
List Addiction issues (Type of addiction, Current/Past, Severity): List Mental health issues (Type, Date of Onset, Current Severity, Fluctuation):
The primary reason I am booking a BodyGuides session: Physical pain reliefImproved physical functionStress reliefEmotional releaseOther
I agree to the Terms & Conditions and Privacy Policy, and consent to receiving a BodyGuides session.
Signature*
Today's Date*
Δ
