Not your first time? RETURNING 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

Email*

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 on a scale of 1 to 10

Use the '+' sign to add conditions.

Pain Location

Since When?

How often do you feel the pain?

Trauma / Insidious (How did it happen?)

Better, Same, or Worse since it started?

Describe your pain: Dull & Achy or Sharp Pain (Muscle, Joint, Nerve)?

Is the pain localized, or do you feel referred pain, numbness, tingling in other areas:

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:

Has there been any major changes to your health status from a medical standpoint?

Yes
No

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

Please describe

Do you take any medication?

Yes
No

Please list all the medication you take:

Anything else new that may pertain to your visit?

Yes
No

Please describe:

*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.

Not your first time? RETURNING Client intake form

RETURNING 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.