CONFIDENTIAL CLIENT INTAKE FORM

PLEASE FILL OUT COMPLETELY, AND "SUBMIT" WHEN COMPLETE.

 Numbers indicate areas of body where you are experiencing pain now.  Please write them down below with further description if needed.

Numbers indicate areas of body where you are experiencing pain now.

Please write them down below with further description if needed.

Name *
Name
Is Texting OK? *
MONTH/DAY/YEAR
(If Applicable)
Type of Accidents
(If Applicable)
Have you seen a health care professional for this condition?
Have you ever received corrective soft tissue therapy, other forms of manual therapy, or body work?
Have you ever had surgery of ANY kind?
e.g. Breast Augmentation, Hernia, Joint, etc.
Do You have any skin disorders or allergies?
Are you taking any medications?
Do you have varicose veins?
Do you have phlebitis?
Do you have loss of bone density?
Do you have post polio syndrome?
Do you have spinal disorder or disease?
Do you have high blood pressure?
Do you have any type of cardiovascular disease?
Are you participating in a regular fitness program?
Do you have any other medical condition?
I have listed all my known medical conditions and physical limitations and I will inform my therapist of any change in the physical health. I understand that a therapist neither diagnoses illness, disease, or any other medical, physical, or mental disorder, nor performs any spinal manipulations.
I have listed all my known medical conditions and physical limitations and I will inform my therapist of any change in the physical health. I understand that a therapist neither diagnoses illness, disease, or any other medical, physical, or mental disorder, nor performs any spinal manipulations.
E-Signature (please type)
Date
Date