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 YYYY dash MM dash DD Gender Male Female Address Street Address City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country E-mail (Bowenwork use only)* Phone (Home)Phone (Work)Phone (Mobile)Occupation Sports/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 CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.