Bowen Registration

Client Registration Form

We appreciate your time is important and to make the best use of it we ask that you complete this online form. It will only take a couple of minutes and will allow your therapist to focus their time on addressing your concerns on the day of your appointment.

Name*

Date of Birth*

Gender*

Male
Female

Occupation

Phone*

Email*

Emergency Contact

Emergency Contact*

(Name)

Emergency Contact No.*

General Questions

Have you had Bowen or BioEnergy treatments before?

Yes
No

Do you exercise or play sport regularly?

Yes
No

If yes, please specify

Do you have any physical job related duties?

Yes
No

Medical History

Are you currently under the care of a health professional?

Yes
No

Doctor's Name

Are you currently taking any medication?

If yes, please specify

Yes
No

Are you or could be pregnant?

Yes
No

Do you have high or low blood pressure?

High
Low
Neither

Have you had any implants, reconstructions or joint replacements? Do you have any scars / scar tissue?

If yes, please specify

Yes
No

Have you had any operations? Any scars/scar tissue?

If yes, please specify

Yes
No

Have you had any recent illnesses?

If yes, please specify

Yes
No

Have you ever had an injury to your Coccyx (Tail bone)?

Leave blank, if unsure

Yes
No

Have you had any broken bones, dislocations or fractures? Do you have any scars/scar tissue?

If yes, please specify

Yes
No

Please check those that apply:*

Medical Information

(Please provide necessary details)

Presenting Condition - Reason for Treatment

Reason for Appointment

How long has the condition been present?

Do you have any pain? If yes, please provide details

Yes
No

Do you feel these symptoms all the time or do they come and go?

Do you have any other symptoms or issues?

Even those you think may not be related

Have you had any other treatments for this presenting condition?

Please check those that apply:

DISCLAIMER*

By returning this form you understand, your therapist is not a Medical Practitioner & does not prescribe medication, treat disease or perform any form of manipulative therapy. Clients should seek the advice of their doctor or other qualified health provider with any questions they may have regarding a medical condition.

I understand & Agree