Distant Craniosacral Intake Form Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Main reason for booking & your intention for the session * Please tick all boxes that apply to you. Do you suffer from: Frequent headaches Epilepsy / seizures Any numbness Cardiac or circulatory issues High blood pressure Any soreness or tenderness Any digestive issues Sleep problems Any allergies Concussion Stress Have you ever had? Whiplash Surgery Fractures or dislocations Significant accident or injury Orthodontic work Any time in hospital Do you Have regular menstruation Know anything about your birth Are you pregnant Anything else I should know Thank you!I look forward to seeing you soon.