Need Help? Call:
408 320-8746
Trio Therapy
Need Help? Call:
408 320-8746
TRIO THERAPY Intake Form
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Which best describes what you are experiencing
Pain
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Getting Worse
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Staying the Same
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Getting Better
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Intermittent
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Decreases with Activity
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Pain
Mild
Getting Worse
Ache
Moderate
Staying the Same
Tension
Getting Better
Discomfort
Constant
Imbalance
Intermittent
Increases with Activity
Decreases with Activity
No Change
Other
Treatment Goals
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Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
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Allergy
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Environmental
Latex
Medical
Area of Complaint
Neck
Left Side of Neck
Right Side of Neck
Upper Back
Left Side of Upper Back
Right Side of Upper Back
Mid Back
Left Side of Mid Back
Right Side of Mid Back
Low Back
Left Side of Low Back
Right Side of Low Back
Chest
Abdomen
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Right Arm
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Right Shoulder
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Right Elbow
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Right Wrist
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Right Hand
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Left Thigh
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Right Leg
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
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Right Hip
Left Groin
Right Groin
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Sacrum
Tailbone (coccyx)
Comments
Neck
Left Side of Neck
Right Side of Neck
Upper Back
Left Side of Upper Back
Right Side of Upper Back
Mid Back
Left Side of Mid Back
Right Side of Mid Back
Low Back
Left Side of Low Back
Right Side of Low Back
Chest
Abdomen
Left Arm
Right Arm
Left Shoulder
Right Shoulder
Left Elbow
Right Elbow
Left Wrist
Right Wrist
Left Hand
Right Hand
Left Leg
Left Thigh
Left Calf
Right Leg
Right Thigh
Right Calf
Left Gluteal
Right Gluteal
Left Hip
Right Hip
Left Groin
Right Groin
Left Knee
Right Knee
Left Ankle
Right Ankle
Left Foot
Right Foot
Sacrum
Tailbone (coccyx)
Headaches
Chronic Daily Headache
Cluster
Headaches
Migraines
Sinus
Tension
Other Headaches
Comments
Chronic Daily Headache
Cluster
Headaches
Migraines
Sinus
Tension
Other Headaches
Musculoskeletal
Arthritis
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Fibromyalgia
Fracture
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Plantar Fasciitis
Spasms / Cramps
Strain/Sprain
Other Musculoskeletal
Comments
Arthritis
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Fibromyalgia
Fracture
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Plantar Fasciitis
Spasms / Cramps
Strain/Sprain
Other Musculoskeletal
Skin
Bruise Easily
Eczema
Hypersensitive Reactions
Psoriasis
Skin Conditions
Sensitive Skin
Comments
Bruise Easily
Eczema
Hypersensitive Reactions
Psoriasis
Skin Conditions
Sensitive Skin
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