Intake Form
Translate Form
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Other
Medical Info
Primary Complaint
Characters:
0
/255
General Health
Characters:
0
/255
Current Treatment
Characters:
0
/255
Past Treatment (from other practitioners)
Characters:
0
/255
Medications
Injuries
Surgeries
Additional Info
Conditions
TMJ (Jaw)
Locking
Characters:
0
/255
Difficulty Opening Jaw
Characters:
0
/255
Difficulty Chewing
Characters:
0
/255
Clenching
Characters:
0
/255
Morning Stiffness
Characters:
0
/255
Ear Ringing
Characters:
0
/255
Ear Stuffiness
Characters:
0
/255
Jaw Pain
Characters:
0
/255
Ear Pressure
Characters:
0
/255
Clicking
Characters:
0
/255
Ear Blockage
Characters:
0
/255
Energy Level
Even
Characters:
0
/255
Fatigue
Characters:
0
/255
Vibrant
Characters:
0
/255
Dull
Characters:
0
/255
Low
Characters:
0
/255
Agitated
Characters:
0
/255
Chaotic
Characters:
0
/255
High
Characters:
0
/255
Clear
Characters:
0
/255
Flat
Characters:
0
/255
Well Being
Sports
Characters:
0
/255
Flexibility
Characters:
0
/255
Range of Motion
Characters:
0
/255
Hobbies
Characters:
0
/255
Interests
Characters:
0
/255
Exercise
Characters:
0
/255
Energy
Do you struggle with insomnia?
Characters:
0
/255
Does your energy fluctuate?
Characters:
0
/255
How long do you sleep on average?
Characters:
0
/255
Is your energy constant?
Characters:
0
/255
What is your energy level upon awakening?
Characters:
0
/255
When is your energy highest?
Characters:
0
/255
When is your energy lowest?
Characters:
0
/255
HT/SI (Fire)
Aversion to Heat
Characters:
0
/255
Acupuncture
Fatigue
Characters:
0
/255
Numbness
Characters:
0
/255
Emotion / Memory
Anxiety Disorder
Characters:
0
/255
Stress
Characters:
0
/255
Female Health
Irregular Periods
Characters:
0
/255
Area of Complaint
Left Side of Neck
Characters:
0
/255
Right Side of Neck
Characters:
0
/255
Left Side of Upper Back
Characters:
0
/255
Right Side of Upper Back
Characters:
0
/255
Left Side of Mid Back
Characters:
0
/255
Right Side of Mid Back
Characters:
0
/255
Left Side of Low Back
Characters:
0
/255
Right Side of Low Back
Characters:
0
/255
Chest
Characters:
0
/255
Abdomen
Characters:
0
/255
Left Arm
Characters:
0
/255
Right Arm
Characters:
0
/255
Left Shoulder
Characters:
0
/255
Right Shoulder
Characters:
0
/255
Left Elbow
Characters:
0
/255
Right Elbow
Characters:
0
/255
Left Wrist
Characters:
0
/255
Right Wrist
Characters:
0
/255
Left Hand
Characters:
0
/255
Right Hand
Characters:
0
/255
Left Leg
Characters:
0
/255
Right Leg
Characters:
0
/255
Left Hip
Characters:
0
/255
Right Hip
Characters:
0
/255
Left Knee
Characters:
0
/255
Right Knee
Characters:
0
/255
Left Ankle
Characters:
0
/255
Right Ankle
Characters:
0
/255
Left Foot
Characters:
0
/255
Right Foot
Characters:
0
/255
Headaches
Cluster
Characters:
0
/255
Rebound
Characters:
0
/255
Sinus
Characters:
0
/255
Migraines
Characters:
0
/255
Chronic Daily Headache
Characters:
0
/255
Headaches
Characters:
0
/255
Tension
Characters:
0
/255
Immune
Allergies
Characters:
0
/255
Cancer
Characters:
0
/255
Other Immune
Characters:
0
/255
Neurological
Parkinsons
Characters:
0
/255
Stroke
Characters:
0
/255
Herniated Disc
Characters:
0
/255
Loss of Sensation
Characters:
0
/255
Sciatic Pain
Characters:
0
/255
Vertebral and Spinal Cord Injury
Characters:
0
/255
Multiple Sclerosis
Characters:
0
/255
Chronic Pain Disorder
Characters:
0
/255
Brain Injury
Characters:
0
/255
Numbness
Characters:
0
/255
Shingles
Characters:
0
/255
Dizziness
Characters:
0
/255
Cerebral Vascular Accident (Stroke)
Characters:
0
/255
Burning
Characters:
0
/255
Seizure Disorder
Characters:
0
/255
Tingling
Characters:
0
/255
Stabbing
Characters:
0
/255
Hearing
Hearing Loss
Characters:
0
/255
Ear Problems
Characters:
0
/255
Skin
Allergic Dermatosis
Characters:
0
/255
Bruise Easily
Characters:
0
/255
Athletes Foot
Characters:
0
/255
Skin Conditions
Characters:
0
/255
Chemical Burn
Characters:
0
/255
Skin Irritations
Characters:
0
/255
Hypersensitive Reactions
Characters:
0
/255
Pigmentary Disorder
Characters:
0
/255
Psoriasis
Characters:
0
/255
Infectious Skin Conditions
Characters:
0
/255
Rash
Characters:
0
/255
Melanoma
Characters:
0
/255
Acne
Characters:
0
/255
Family History
Respiratory
Characters:
0
/255
Cardiovascular
Characters:
0
/255
Arthritis
Characters:
0
/255
Musculoskeletal
Strain/Sprain
Characters:
0
/255
Amyotrophic Lateral Sclerosis (ALS)
Characters:
0
/255
Arthritis
Characters:
0
/255
Tendonitis/Bursitis
Characters:
0
/255
Dislocation
Characters:
0
/255
Osteoarthritis
Characters:
0
/255
Osteoporosis
Characters:
0
/255
Carpal Tunnel Syndrome
Characters:
0
/255
Fracture
Characters:
0
/255
Artificial Joints / Special Equipment
Characters:
0
/255
Plantar Fasciitis
Characters:
0
/255
Joint Injury
Characters:
0
/255
Whiplash
Characters:
0
/255
Chronic Fatigue Syndrome
Characters:
0
/255
Psoriatic Arthritis
Characters:
0
/255
Jaw Pain (TMJD)
Characters:
0
/255
Sinus Problems
Characters:
0
/255
Scleroderma
Characters:
0
/255
Fibromyalgia
Characters:
0
/255
Scoliosis
Characters:
0
/255
Other Musculoskeletal
Characters:
0
/255
Reproductive
Menopause
Characters:
0
/255
Ovarian Cysts/Tumors
Characters:
0
/255
Gastrointestinal
Poor Appetite
Characters:
0
/255
Digestive Conditions
Characters:
0
/255
Eating Disorder
Characters:
0
/255
Emotion / Mood
Stress Response and Coping Strategies
Characters:
0
/255
Overall mood and energy level
Characters:
0
/255
Rate the stress in your life (1-10)
Characters:
0
/255
Anxiety
Characters:
0
/255
Depression
Characters:
0
/255
Fear
Characters:
0
/255
Grief
Characters:
0
/255
Negative Self-Talk
Characters:
0
/255
PTSD
Characters:
0
/255
Anger
Characters:
0
/255
Sadness
Characters:
0
/255
Review & Agree
Clinic Policy
(Review Required)
You need to review and accept this before submitting
Signature
×
Submit Form
×