FIRST TIME Client Intake Form

If you have more than one condition or concern you'd like to address, please take a moment to provide as much information for each one.

Date*

Name*

First Last

Gender*

Male
Female

Birth Date*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary phone number*

Home phone

Work phone

Fax

Email*

Occupation/Work/Trade

Emergency contact person

First Last

Relationship (spouse, parent, child, etc.)

Phone

List all the conditions/injuries/concerns, in order of priority, you'd like to address during your session. (Pain scale: 1 = I barely feel it, 10 = worst pain I've ever experienced)

Pain location	Please describe

Use the '+' sign to add conditions.

How often do you feel the pain?

Better, Same, or Worse since it started?

Dull & Achy or Sharp Pain (Muscle, Joint, Nerve)?

Pain Referral, Numbness, Tingling:

Other signs and symptoms (Other pain elsewhere):

Does it affect you when you sleep?

Yes
No

Please describe your sleeping position: stomach, back, side, etc. Also include arm position in your description (arm behind head, over eyes, etc.)

When is it at its worst during your day?

Morning
Evening
No difference

Relieving Factors (What makes it feel better?):

Aggravating Factors (What makes it feel worse?). Describe which movements or positions cause you pain:

Have you consulted with a doctor?

Yes
No

What was the doctor's diagnosis?

Past Treatment History:

Please list types of therapies or medical treatments received for this condition. Please take a moment to describe them, and whether they have improved/did nothing/or worsen your condition.

X-Ray / MRIs:

If you have received any, please bring them to your first appointment, or provide a digital copy.

Past Medical History:

Please check any condition that pertains to you, either now or in the past

Please describe

Do you have any family history of cancer, heart disease, diabetes, high blood pressure?

Do you take any medication?

Yes
No

Please list all the medication you take:

Do you have any allergies?

Yes
No

Please list your allergies

Do you carry an Epipen?

Yes
No

Are you physically active/participate in any sport or activity?

Yes
No

Please describe:

Is there any other information that may pertain to your visit?

Yes
No

Please describe:

How did you hear about us (who referred you)?

*The information in this form will be kept confidential except as required by law. Your written permission will be required to release any information. It is important to be accurate so that we can ensure it is safe for you for receive treatment or engage in physical activity. If your health status or contact information changes in the future, please let us know.