Bowen Therapy Intake Form
Thank you for you interest in the Bowen Technique. Please fill out the following intake questions 2-3 days prior to your initial appointment. To read more about the conditions that Bowen can address, visit: www.dynamicmedicine.net/the-bowen-technique/conditions/
Name (first, last) *
Your answer
Email
Your answer
Phone Number
Please provide the best number to use for scheduling purposes
Your answer
Age
Your answer
Sex
Your answer
Occupation
Your answer
Sports/hobbies/activities
Your answer
Previous operations/accidents/illnesses: *
Please record dates and details. Please make special care to note any breast/pec implants or reconstructive jaw surgery, both of which are contraindicated with certain Bowen Procedures.
Your answer
Presenting Conditions: *
Your answer
Primary Health Goals *
In what area(s) do you want to see the most improvement? What signs and symptoms would you most like to resolve? What does your healthiest self look like? Please be as specific as possible.
Your answer
Prior Treatment for Presenting Conditions *
Please note that, because of the subtlety of Bowenwork and the body's continuing response to it, other forms of MANIPULATIVE THERAPY performed up to four days before, or five days after, a Bowen session may interfere with its effectiveness.
Required
Other Relevant Comments:
Your answer
Informed Consent
I request and consent to Bowen treatment with Carol-Ann Galego. I understand that no promise or guarantee of specific results can be made. I understand that Bowen treatment should not be considered as a replacement for treatment by a Medical Doctor.
I have read and understood the above consent for myself and/or my child. *
Submit
Never submit passwords through Google Forms.
GoogleForms
This content is neither created nor endorsed by Google.