Rebecca Cook LLC
rcookotr@gmail.com
Client Name
Date of Birth
Client's Address:
Name of Emergency Contact
Emergency Contact email and phone number:
List current problems you are experiencing:
When did you notice these starting?
How do these problems impact your daily life (sleep, relaxation, eating, bowel movements, work, quality family time, exercising, having fun, doing things you like, etc.)
What is your goal for your sessions?
Optional: Please list current medications and supplements you are taking and the reason you are taking them (if you do not take any prescription medications, over the counter medications, or supplements write in NONE):
Have you had any recent injuries or accidents? (If yes, please share details and how they are affecting you now.)
Wellness sessions should not be construed as a substitute for medical examination, diagnosis, or treatment and that I understand I should see a physician, chiropractor, or other qualified medical specialist for any mental or physical ailment of which I am aware. I will inform my practitioner of any changes in my health status at least 24-hours prior to any session.(Place your initials in the box.)
Electronic Signature for the Client or Legal Guardian: Please type your name in the box below*
*Typing your name in the box below constitutes your electronic signature acknowledging the information on this form is accurate and correct. Your electronic signature is legally binding and by signing you acknowledge you are legally authorized to do so.
Date this form was completed.
First Name: *
Last Name: *
Email: *
Phone: *
Website:
