New Client Form Please complete this form before coming to your first visit. This form will be sent to me via email so you don't have to print it. Name* First Last Date of Birth GenderMaleFemaleAddress Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country E-mail (Bowenwork use only)* Phone (Home)Phone (Work)Phone (Mobile)OccupationSports/Hobbies Emergency Contact First Last Reffered By First Last _____________________________________________________________Please check all that apply Abdominal / Digestive Problem Allergies / Hay Fever Arthritis Asthma Ankle Problem Back Pain Bed Wetting (children) Bone Spurs Breast Lump Breast Pain Breast Implants Bronchitis Bunion Bursitis Buttock Pain Cancer Carpal Tunnel Syndrome Chest Pain Colic (baby) Constipation Diabetes Diaphragm Pain or Tightness Diarrhea Dizziness Ear or Eye Problem Edema, General Elbow Pain, Tennis or Golf Fatigue, Chronic Fibromyalgia or Polymyalgia Fibroids - (location): Fracture Fallen on Tailbone / Coccyx Gall bladder Problem Heating pad / Ice Pack Usage Heating / Ccoling Salve Usage Hammer Toes Hamstring Pain or Tightness Headaches Heart Problem Hernia Hip Pain Hip Replacement Incontinence / Bladder (adult) Infertility Jaw / TMJ Problem Joint Replacement Knee Problem Liver Problem Lung problem Magnet Usage Migraines Numbness Orthodontia, Extensive Orthotics in Shoes Osteoporosis Pain, Other Pelvic Pain Plantar Fasciitis or Neuroma PMS or Menopause Pregnancy Prostate Problem Rib pain / subluxation Sacral Pain Sciatica Scoliosis Shin Splints Shoulder Problem Sinus Problem Sleep / Energy Problem Tinnitus Uterine or Ovary Problem Wrist or Thumb Pain Other Describe your condition(s), including length of time experienced. Please list all accidents, injuries, surgeries and falls that might be relevant in any way; include dates of occurrence.List activities compromised by condition(s) Current medications (it is sufficient to state purpose, such as cholesterol, high blood pressure, osteoporosis)Recent hands-on modalities receivedI have stated, to the best of my knowledge, my known medical conditions. I understand that Bowenwork is given for the purpose of stress reduction, relief from muscular tension and/or spasm, facilitation of circulation and energy flow, and relief from stiffness. I understand that the practitioner does not diagnose illness or disease, nor treat specific physical or mental disorders. I will inform my practitioner of any changes in my condition, and will contact my practitioner should I have any concerns.* I Agree This iframe contains the logic required to handle AJAX powered Gravity Forms.