PATIENT INTAKE FORM

Personal Information
Name:____________________________________ Date of birth:_____________________

Male / Female

E-mail:__________________________________________________ Phone #:__________________________

Address:___________________________________________________________________________________
Emergency contact:________________________________________ Phone #:__________________________
Occupation:______________________________________________ Date of initial visit:_________________
Join our e-mail list to keep up to date on all things HPBT and to get valuable tips and advice! Y / N
How did you hear about HPBT?

The following information will be used to help plan safe and effective treatments. Please answer the
questions to the best of your knowledge.
Have you had a Bowen or any other alternative medical treatment before?

Yes

No

If yes, which ones and how often?

Do you have any difficulty lying on your front, back, or side?

Yes

No

If yes, please explain

Are you wearing contact lenses dentures a hearing aid?

Do you sit for long hours at a workstation, computer, or driving?

Yes

No

If yes, please describe

Do you perform any repetitive movement in your work, sports, or hobby?

Yes

No

If yes, please describe

Do you experience stress in your work, family, or other aspect of your life?

Yes

No

If yes, how has it affected your health? muscle tension anxiety insomnia irritability other

______

What particular goals do you have in mind for this treatment?

Please circle any specific areas you would like to concentrate on during the treatment:

Continued on page 2

Medical History
Are you currently under medical supervision? Yes

No

If yes, please explain

Are you currently taking any medication?

Yes

No

If yes, please list

Have you had any dental work done (cavities, implants, extractions etc)?

Yes

No

If yes, please list

Please check any condition listed below that applies to you:

Contagious
conditions
Open sores or
wounds
Multiple Sclerosis
Dizziness
Joint stiffness of
swelling
Sprains/strains
Current fever
Swollen glands
Allergies/sensitivity
Heart condition
Joint disorder
(rheumatoid
/osteoarthritis/tendo
nitis/ artificial)

Ulcers
Bowel disorders
Liver disease
Osteoporosis
High or low blood
pressure
Decreased sensation
Epilepsy
Headaches/migraines
Cancer
Diabetes
Circulatory disorder
(Deep vein thrombosis/
blood clots etc.)

TMJ
Carpal tunnel
syndrome
Back/neck problems
Fibromyalgia
Varicose veins
Kidney disease
Asthma
Chronic cough
Shortness of breath
Smoking
Recent accident/
injury/ fracture or
surgery
Other
_____________________

Is there anything else, health history or otherwise, that may be useful to know?

_________________________________________________________________________
_________________________________________________________________________
For comfort and best results please wear loose fitting clothing to your session.
Should you be ill at the time of any appointment, please kindly reschedule.
Please give 24 hours notice of cancellation to avoid charges.
A parent or legal guardian must provide written consent and accompany anyone under age 17.
I,

(print name) understand that the treatment I receive is provided

for the basic purpose of relaxation and relief of muscular tension. If I experience any pain or discomfort during this
session, I will immediately inform the therapist so that adjustments can be made. I further understand that a Bowen
treatment should not be construed as a substitute for medical examination, diagnosis and that I should see a
qualified medical specialist for any mental or physical ailment that I am aware of. I understand that Bowen Health
Therapists are not qualified to diagnose, prescribe, or treat any physical or mental illness, and that nothing said in
the course of the session given should be construed as such. Because Bowen treatments should not be performed
under certain medical conditions, I affirm that I have stated all my known medical conditions, and answered all

questions honestly. I agree to keep the therapist updated as to any changes in my medical profile and understand
that there shall be no liability on the therapists part should I fail to do so.
Patient Signature

Date:____________________

Therapist Signature

Date: _________________________