Need Help? Call:
(770) 632-8814
Need Help? Call:
(770) 632-8814
Intake Form
Profile
Medical
Insurance
Conditions
Accept & Send
Personal Info
First Name *
Last Name *
Date of Birth *
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Gender *
M
F
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Address *
City *
Country
Australia (+61)
Canada (+1)
Ireland (+353)
New Zealand (+64)
United Kingdom (+44)
United States (+1)
------------
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
Medical Info
Primary Complaint
General Health
Source of Referral
Current Treatment
Past Treatment (from other practitioners)
Medications
Injuries
Surgeries
Additional Info
Insurance Info
Insurer's Name
Adjuster's Name
Policy Number
Office Address
City
Country
Prov / State
Postal Code / Zip
Phone
Fax
Email Address
Claims / Benefits
Conditions
Well Being
Exercise
Flexibility
Hobbies
Interests
Range of Motion
Sports
Supplements
Water Intake
Comments
Exercise
Flexibility
Hobbies
Interests
Range of Motion
Sports
Supplements
Water Intake
Treatment Goals
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
Comments
Improve Lifestyle
Improve Symptoms
Improve Well Being
Pain Relief
Rehabilitation
Stress Relief
Support in Healing/Recovery
Other
Current Complaint
Pain Severity: 1-10
Date of Injury?
Comments
Pain Severity: 1-10
Date of Injury?
Physical Activities You Participate In
Crossfit
Golf
Pilates
Running
Swimming
Tennis
Weight Lifting
Yoga
Other Activities
Comments
Crossfit
Golf
Pilates
Running
Swimming
Tennis
Weight Lifting
Yoga
Other Activities
Emotion / Mood
Anxiety
Depression
Fear
Rate the stress in your life (1-10)
Comments
Anxiety
Depression
Fear
Rate the stress in your life (1-10)
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
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)
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
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Comments
Cluster
Headaches
Migraines
Rebound
Sinus
Tension
Family History
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
Comments
Arthritis
Cancer
Cardiovascular
Diabetes
Respiratory
Cardiovascular
Cardiovascular Accident
Cold Feet
Cold Hands
Fainting Spells
Heart Attack
High Blood Pressure
Low Blood Pressure
Myocardial infarction
Pacemaker
Swelling
Comments
Cardiovascular Accident
Cold Feet
Cold Hands
Fainting Spells
Heart Attack
High Blood Pressure
Low Blood Pressure
Myocardial infarction
Pacemaker
Swelling
Endocrine
Adrenal Fatigue
Diabetes
Hyperthyroidism
Hypothyroidism
Comments
Adrenal Fatigue
Diabetes
Hyperthyroidism
Hypothyroidism
Gastrointestinal
Acid Reflux
Celiac Disease
Constipation
Crohn's Disease
Diarrhea
Digestive Conditions
Hiatal Hernia
Irritable Bowel Syndrome
Ulcerative Colitis
Other Gastrointestinal
Comments
Acid Reflux
Celiac Disease
Constipation
Crohn's Disease
Diarrhea
Digestive Conditions
Hiatal Hernia
Irritable Bowel Syndrome
Ulcerative Colitis
Other Gastrointestinal
Hearing
Ear Problems
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Comments
Ear Problems
Meniere Disease
Motion Sickness
Tinnitus
Vertigo
Other Hearing
Immune
Allergies
Anaphylaxis
Cancer
Rheumatoid Arthritis
Other Immune
Comments
Allergies
Anaphylaxis
Cancer
Rheumatoid Arthritis
Other Immune
Kidney
Kidney Stones
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Comments
Kidney Stones
Urinary Incontinence
Urinary Tract Infection
Other Kidney
Musculoskeletal
Adhesive Capsulitis
Amyotrophic Lateral Sclerosis (ALS)
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Baker's Cyst
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Dislocation
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Fibromyalgia
Gout
Hereditary/Congenital Deformity
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Muscular Dystrophy
Myasthenia Gravis
Osgood-Schlatter Disease
Osteoarthritis
Osteomalacia
Osteoporosis
Paget Disease
Plantar Fasciitis
Psoriatic Arthritis
Recti Diastasis
Scleroderma
Scoliosis
Sinus Problems
Spasms / Cramps
Spondylolisthesis
Strain/Sprain
Temporomandibular Joint Dysfunction
Tendonitis/Bursitis
Torticollis
Whiplash
Other Musculoskeletal
Comments
Adhesive Capsulitis
Amyotrophic Lateral Sclerosis (ALS)
Ankylosing Spondylitis
Arthritis
Artificial Joints / Special Equipment
Baker's Cyst
Bone or Joint Disease
Broken Bone / Fracture
Carpal Tunnel Syndrome
Chronic Myofascial Pain Syndrome
Compartment Syndrome
Degenerative Disk Disease
Dislocation
Dupuytren's Contracture
Ehlers-Danlos Syndrome
Fibromyalgia
Gout
Hereditary/Congenital Deformity
Jaw Pain (TMJD)
Joint Injury
Joint Stiffness / Swelling
Muscular Dystrophy
Myasthenia Gravis
Osgood-Schlatter Disease
Osteoarthritis
Osteomalacia
Osteoporosis
Paget Disease
Plantar Fasciitis
Psoriatic Arthritis
Recti Diastasis
Scleroderma
Scoliosis
Sinus Problems
Spasms / Cramps
Spondylolisthesis
Strain/Sprain
Temporomandibular Joint Dysfunction
Tendonitis/Bursitis
Torticollis
Whiplash
Other Musculoskeletal
Neurological
Bell's Palsy
Brain Injury
Cerebral Palsy
Chiari Malformation
Dizziness
Epilepsy
Fatigue
Herniated Disc
Loss of Sensation
Multiple Sclerosis
Numbness
Parkinsons
Peripheral Neuropathy
Sciatic Pain
Seizure Disorder
Shingles
Sleeping Disorders
Stroke
Tingling
Twitching of Face
Other Neurological
Comments
Bell's Palsy
Brain Injury
Cerebral Palsy
Chiari Malformation
Dizziness
Epilepsy
Fatigue
Herniated Disc
Loss of Sensation
Multiple Sclerosis
Numbness
Parkinsons
Peripheral Neuropathy
Sciatic Pain
Seizure Disorder
Shingles
Sleeping Disorders
Stroke
Tingling
Twitching of Face
Other Neurological
Reproductive
Breast Disorder
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pregnancy
Other Reproductive
Comments
Breast Disorder
Menstrual Cycle Disorder
Ovarian Cysts/Tumors
Pregnancy
Other Reproductive
Respiratory
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Shortness of Breath
Tuberculosis
Other Respiratory
Comments
Asthma
Bronchitis
Chronic Cough
COPD
Cystic Fibrosis
Emphysema
Infectious Respiratory Conditions
Respiratory Conditions
Respiratory Tract Infection
Shortness of Breath
Tuberculosis
Other Respiratory
Skin
Allergic Dermatosis
Athlete's Foot
Bruise Easily
Eczema
Hypersensitive Reactions
Infectious Skin Conditions
Psoriasis
Rash
Skin Conditions
Skin Irritations
Dry Skin
Other Skin
Comments
Allergic Dermatosis
Athlete's Foot
Bruise Easily
Eczema
Hypersensitive Reactions
Infectious Skin Conditions
Psoriasis
Rash
Skin Conditions
Skin Irritations
Dry Skin
Other Skin
Miscellaneous
ADHD
Autism
Insomnia
Loss of Balance
Mental Health Issues
Surgical Pins or Wire
Vision Loss
Vision Problems
Other Medical Conditions
Other Diagnosed Diseases
Comments
ADHD
Autism
Insomnia
Loss of Balance
Mental Health Issues
Surgical Pins or Wire
Vision Loss
Vision Problems
Other Medical Conditions
Other Diagnosed Diseases
Accept & Send
I accept the
Informed Consent
Submit Intake
×