CLIENT INTAKE FORM

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Personal Info

First Name

Last Name

Pronouns

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Contact Info

Mobile Phone

Home Phone

Work Phone

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor

Doctor's Name

Doctor's Phone

Doctor's Address

Other

Medical Info

Primary Complaint

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General Health

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Current Treatment

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Past Treatment (from other practitioners)

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Medications

Injuries

Surgeries

Additional Info

Conditions

Acupuncture

Sciatica

Arthritis

Bursitis/Tendonitis

Carpal Tunnel

Nerve Pain

Numbness

TMJ (Jaw)

Female Health

Health Questions

Feet

Treatment Goals

Stress Relief

Support in Healing/Recovery

Health Advice for Healing

Improve Lifestyle

Improve Symptoms

Improve Well Being

Pain Relief

Rehabilitation

Other

Well Being

Infectious

Pneumonia

Strep

Epstein Barr

Lyme Disease

COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)

Oncology

Vocal History

Vocal Injury

Vocal Surgery

Diagnosis of Vocal Injury

Vocal Health

Difficulty Swallowing

Difficultly Speaking

Acid Reflux

Infant

Torticollis

Area of Complaint

Brain Disorders

Acute Stress Disorder

Bipolar Disorder

Depression

Panic Disorder

PTSD

Social Anxiety Disorder

Headaches

Chronic Daily Headache

Cluster

Headaches

Migraines

Rebound

Sinus

Tension

Other Headaches

Neurological

Musculoskeletal

Skin

Immune

Endocrine

Respiratory

Cardiovascular

Blood

Kidney

Electrolyte Imbalance

Kidney Stones

Renal Cysts

Urinary Incontinence

Urinary Tract Infection

Bladder Disorder

Chronic Kidney Disease

Congenital Kidney Disease

Other Kidney

Hearing

Conductive Hearing Loss

Ear Problems

Hearing Loss

Meniere Disease

Motion Sickness

Tinnitus

Vertigo

Other Hearing

Reproductive

Gastrointestinal

General Injury Related Questions

What is the next competition/challenge?

Previous sports-related injuries?

Treatment of previous injury?

Physical Therapy

Chiropractic

OTC medications

Pain medications or steroids

Surgery (type/year)

Complications from that injury?

Miscellaneous

Prenatal (check boxes to enter details below)

Massage Goals

Accident Info

Date of Injury

MVA Claim

Workers Comp Claim

Crime Victim Comp.

Which best describes what you are experiencing

Current Complaint

Physical Activities You Participate In

Number of Times of Week You Practice

Once a week

2-4 times a week

More than 4 times a week

Less than a couple of times a month

Allergy

Medical

Miscellaneous

Coconut Oil

Environmental

Food

Latex

Emotion / Mood

Anxiety

Depression

Grief

Overall mood and energy level

PTSD

Rate the stress in your life (1-10)

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