Kinetic Chain Release New Client Form

CLIENT INFORMATION:

Name:

Today's Date:

Home Phone Number:

Cell Phone Number:

Email:

Address:

Address Line 1

Address Line 2

City

State

Zip Code

Birthdate:

Age:

Marital Status:

Number of Children:

Occupation:

Years on Job:

Work Phone:

Are you currently a client of The Well of Life Center?

Yes
No

If yes, who is your clinician?

In Case of Emergency, please contact:

Emergency Contact Name:

Emergency Contact Phone Number:

Relationship:

HEALTH & HISTORY QUESTIONNAIRE:

Please check all CURRENT conditions:

Please check all PAST conditions:

Please elaborate on any current or past conditions:

List any injuries or surgeries you have had, and their approximate dates:

Have you ever been in a car accident?

Yes
No

If so, please list approximate dates and injuries:

List your stress-reduction activities, hobbies, exercise, and/or sport participation:

List any medications you are taking, and the condition they are treating:

What are your goals for this session?

List any areas of tension, stress, and/or pain you wish to be addressed: 

Additional notes:

Agreement and Release of Liability:

Please click HERE to read our KCR Liability Release Form and Agreement and Release of Liability. Then, sign by typing your full name in the box above. By signing, you are acknowledging that you have read and accept the terms and conditions of Agreement and Release of Liability.

WELLNESS SERVICES

Please note…

CLIENT INFORMATION:

In Case of Emergency, please contact:

HEALTH & HISTORY QUESTIONNAIRE:

Contact Us

Hours

Well of Life Center for Holistic Healthcare

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