COPY OF CranioSacral Intake Form
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Conditions
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
Injuries
Surgeries
Additional Info
Conditions
Infant
Special Needs
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Torticollis
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Gas
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Constipation
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Abdominal Conditions
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Feeding Issues
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Colic
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Skin Sensitivities
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Birth Trauma
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Allergies
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Stress
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Other Conditions
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Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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Chest
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Abdomen
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Left Arm
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Right Arm
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Left Leg
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Right Leg
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Headaches
Chronic Daily Headache
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Tension
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Cluster
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Migraines
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Rebound
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Sinus
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Other Headaches
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Neurological
Tingling
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Cerebral Vascular Accident (Stroke)
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Parkinsons
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Stabbing
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Seizure Disorder
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Herniated Disc
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Transient Ischemic Attacks (TIA)
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Shingles
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Multiple Sclerosis
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Loss of Sensation
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Dizziness
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Stroke
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Cerebrospinal Fluid Leak
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Vertebral and Spinal Cord Injury
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Sciatic Pain
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Numbness
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Chronic Pain Disorder
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Epilepsy
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Burning
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Brain Injury
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Other Neurological
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Musculoskeletal
Arthritis
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Dislocation
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Fracture
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Osteoporosis
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Degenerative Disk Disease
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Carpal Tunnel Syndrome
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Joint Injury
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Artificial Joints / Special Equipment
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Torticollis
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Scoliosis
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Whiplash
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Strain/Sprain
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Plantar Fasciitis
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Jaw Pain (TMJD)
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Osteoarthritis
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Chronic Myofascial Pain Syndrome
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Sinus Problems
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Chronic Fatigue Syndrome
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Tendonitis/Bursitis
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Fibromyalgia
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Other Musculoskeletal
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Endocrine
Pituitary and Growth Disorder
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Prostate Condition
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Diabetes
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Hyperthyroidism
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Hypothyroidism
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Other Endocrine
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Reproductive
Premenstrual Syndrome
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Pregnancy
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Endometriosis
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Menopause
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Other Reproductive
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Respiratory
Shortness of Breath
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COPD
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Asthma
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Other Respiratory
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Blood
Hepatitis
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Anemia
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Bleeding Disorder
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HIV/AIDS
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High Cholesterol
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Thrombosis/Embolism
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Other Blood
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Gastrointestinal
Celiac Disease
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Diverticulitis
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Eating Disorder
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Crohn's Disease
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Irritable Bowel Syndrome
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Other Gastrointestinal
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Hearing
Meniere Disease
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Motion Sickness
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Tinnitus
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Vertigo
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Ear Problems
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Hearing Loss
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Other Hearing
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Cardiovascular
Heart Attack
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Blood Pressure
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Pacemaker
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Blood Clots
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Lymphedema
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Aneurysm
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Other Cardiovascular
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Immune
Rheumatoid Arthritis
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Allergies
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Leukemia
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Cancer
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Other Immune
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Miscellaneous
Insomnia
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Other Medical Conditions
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Other Diagnosed Diseases
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Emotion / Mood
Negative Self-Talk
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Anger
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Other Emotions
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Anxiety
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PTSD
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Fear
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Sadness
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Depression
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Grief
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Despair
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