CT Center for CranioSacral Therapy
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Emergency Contact
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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
Energy
What is your energy level upon awakening?
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When is your energy highest?
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When is your energy lowest?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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Treatment Goals
Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Health Advice for Healing
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Improve Lifestyle
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Other
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Female Health
Severe Menstrual Pain
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Hysterectomy
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Number of Pregnancies
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Number of Live Births
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Irregular Periods
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Endometriosis
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Osteoporosis
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Currently Pregnant
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Pelvic Pain
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TMJ (Jaw)
Grinding
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Jaw Pain
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Clicking
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Locking
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Difficulty Chewing
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Morning Stiffness
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Difficulty Opening Jaw
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Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Energy Level
Fatigue
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Flat
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High
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Agitated
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Low
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Chaotic
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Vibrant
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Clear
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Dull
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Even
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KID/UB (Water)
Weak Leg/Knees
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Weakness/Pain in Lower Back
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Bladder Problems
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Brain Foggy
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Hearing Problems
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Poor Memory
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Genetics
Ehlers-Danlos Syndromes
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Loeys-Dietz Syndrome
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Marfan Syndrome
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Other
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Male Health
History of Back Injury
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Nocturnal Urination
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Painful Urination
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Health Questions
Meniere Disease
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Migraines/Headaches
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Stroke
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Cancer
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Vertigo
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Concussion
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Gastrointestinal
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Hearing Impairment
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Heart Condition
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Emotion / Memory
Anxiety Disorder
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Mood Disorder
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Stress
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LIV/GB (Wood)
Blurred Vision
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Depression/Stress
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Dizziness
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Joints/Neck/Shoulder Pain
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Muscle Cramping/Twitching
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Ringing in Ears
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SP/ST (Earth)
Easily Bruising & Bleeding
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Indigestion/Heartburn
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Muscles Feel Tired Often
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Nausea/Vomiting
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Infectious
Epstein Barr
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Lyme Disease
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Willing to wash hands before entering clinic
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Willing to wash hands before leaving clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you been tested for COVID?
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Have you had the antibody test?
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Fever Over 100.4 degrees
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New Onset of Cough
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Worsening Chronic Cough
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Difficulty Breathing
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Persistent Pain in Chest
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Decrease or sudden loss of taste and smell
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Have you had a new onset of muscle aches and pain since the emergence of the virus?
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Unexplained Fatigue/Malaise/Muscle Aches (Myalgia)
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Chills
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Pink eye (conjunctivitis)
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Nausea
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Vomiting
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Diarrhea
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Have you seen any new marks, rashes, spots, bumps, or other lesions on your skin?
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Contact with someone with COVID
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Had close contact with a confirmed case of COVID-19 without wearing PPE
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Contact with someone who was in contact with COVID
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Contact with anyone with acute respiratory Illness
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Recent domestic air travel
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Recent international air travel
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Recent travel to area with high infection rates
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Recent travel outside your province within the past 14 days
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Been in group where social distancing not observed
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Are you considered high risk?
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Spend time around anyone that is high risk
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If over 70, symptoms of delirium?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Status
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Vocal Health
Vocal Fatigue
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Hoarseness
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Difficulty Swallowing
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low Back
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Left Side of Low Back
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Right Side of 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 Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Brain Disorders
Social Anxiety Disorder
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Anorexia Nervosa
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Depression
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Antisocial Personality Disorder
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Generalized Anxiety Disorder
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Asperger Syndrome
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Obsessive Compulsive Disorder
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Autism
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Obsessive Compulsive Personality Disorder
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Acute Stress Disorder
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Bipolar Disorder
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Panic Disorder
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PTSD
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ADD
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Borderline Personality Disorder
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Schizophrenia
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ADHD
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Bulimia Nervosa
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Sleep Disorder
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Agoraphobia
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Claustrophobia
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Headaches
Chronic Daily Headache
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Cluster
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Headaches
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Migraines
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Rebound
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Sinus
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Tension
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Other Headaches
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Musculoskeletal
Osgood-Schlatter Disease
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Ankylosing Spondylitis
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Scleroderma
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Chronic Fatigue Syndrome
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Whiplash
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Fracture
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Osteoarthritis
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Arthritis
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Scoliosis
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Chronic Myofascial Pain Syndrome
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Gout
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Osteomalacia
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Artificial Joints / Special Equipment
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Spasms / Cramps
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Compartment Syndrome
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Hereditary/Congenital Deformity
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Osteoporosis
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Baker's Cyst
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Spondylolisthesis
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Degenerative Disk Disease
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Jaw Pain (TMJD)
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Paget Disease
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Bone Disease
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Strain/Sprain
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Dislocation
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Joint Injury
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Joint Stiffness / Swelling
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Plantar Fasciitis
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Bone or Joint Disease
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Temporomandibular Joint Dysfunction
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Dupuytren's Contracture
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Muscular Dystrophy
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Adhesive Capsulitis
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Psoriatic Arthritis
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Broken Bone / Fracture
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Tendonitis/Bursitis
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Ehlers-Danlos Syndrome
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Myasthenia Gravis
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Amyotrophic Lateral Sclerosis (ALS)
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Recti Diastasis
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Carpal Tunnel Syndrome
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Torticollis
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Fibromyalgia
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Other Musculoskeletal
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Gastrointestinal
Irritable Bowel Syndrome
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Acid Reflux
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Eating Disorder
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Poor Appetite
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Adaptive Aids
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Esophageal Disorder
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Stomach Disorder
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Celiac Disease
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Fecal Impaction
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Ulcerative Colitis
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Constipation
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Gastroparesis
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Crohn's Disease
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Hiatal Hernia
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Diarrhea
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Intestinal Gas/Bloating
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Digestive Conditions
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Intestinal Polyps
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Abdominal Hernia
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Diverticulitis
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Other Gastrointestinal
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Neurological
Multiple Sclerosis
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Shingles / Herpes
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Twitching of Face
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Cerebrospinal Fluid Leak
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Chiari Malformation
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Numbness
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Sleeping Disorders
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Vertebral and Spinal Cord Injury
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Chronic Pain Disorder
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Parkinsons
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Stabbing
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Bell's Palsy
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Dural Ectasia
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Peripheral Neuropathy
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Stroke
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Brain Injury
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Epilepsy
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Post Polio Syndrome
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Syringomyelia
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Burning
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Fibromyalgia
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Sciatic Pain
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Tethered Cord
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Carpal Tunnel
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Huntington Disease
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Seizure Disorder
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Tingling
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Cerebral Palsy
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Loss of Sensation
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Shingles
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Transient Ischemic Attacks (TIA)
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Cerebral Vascular Accident (Stroke)
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Other Neurological
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Blood
Thrombosis/Embolism
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Anemia
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Bleeding Disorder
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Blood Thinner Medication
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Fainting Spells
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Hepatitis
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HIV/AIDS
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Stroke
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Other Blood
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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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Conductive Hearing Loss
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Ear Problems
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Hearing Loss
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Other Hearing
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Skin
Dermatographia
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Non-Surgical Scars
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Bruise Easily
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Cardiovascular
Valve Disorders
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Aneurysm
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Blood Clots
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Fainting Spells
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Heart Condition
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Postural Orthostatic Tachycardia Syndrome
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Raynaud Disease
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Other Cardiovascular
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Immune
HIV/Aids
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Infectious Mononucleosis
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Lupus
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Rheumatoid Arthritis
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Sjogren's Syndrome
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Allergies
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Anaphylaxis
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CVID
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Other Immune
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Family History
Arthritis
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Cancer
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Cardiovascular
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Diabetes
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Respiratory
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General Injury Related Questions
Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Weakened Immune Function
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ADHD
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Surgical Pins or Wire
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Autism
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Hearing Impaired
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Loss of Balance
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Vision Problems
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Other Medical Conditions
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Other Diagnosed Diseases
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Prenatal (check boxes to enter details below)
Due Date
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Sciatica
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Accident Info
Date of Injury
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Which State?
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MVA Claim
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Workers Comp Claim
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Crime Victim Comp.
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Physical Activities You Participate In
Pilates
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Waterpolo
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Rugby
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Weight Lifting
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Running
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Yoga
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Baseball
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Crossfit
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Soccer
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Football
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Softball
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Golf
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Other Activities
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Number of Times of Week You Practice
Once a week
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2-4 times a week
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More than 4 times a week
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Less than a couple of times a month
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Allergy
Miscellaneous
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Coconut Oil
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Environmental
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Food
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Latex
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Mastocytosis
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MCAD
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Medical
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Emotion / Mood
Despair
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Grief
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Sadness
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Mental Abuse History
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Stress Response and Coping Strategies
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Anger
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Negative Self-Talk
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Anxiety
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Other Emotions
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Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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