Client Intake Form

CLIENT HISTORY INFORMATION
Please complete our Intake Form to the best of your ability. Your information is stored in a secure HIPAA compliant environment.
Full Name

First NameLast Name
Parent Name (if under 18 years old)

First NameLast Name
Cellphone Number
Email
example@example.com
Date of Birth

MonthDayYear
Date
Today's Date

MonthDayYear
Date
Referred by

First NameLast Name
What are your goals?

Other
If you checked more than one goal, please list the order of priority:
Please share some background information (for example, when did the issue start, how often, what else have you tried?)

Rows	Yes	No
Are you currently pregnant?
Are you currently treated for a neurological, autoimmune condition or cancer?
Are you currently treated for a chronic pain condition such as fibromyalgia?
Have you had corrective eye surgery for lazy eye or crossed eye?
Have you had an active disc or spinal injury?
Have you experienced issues related to a traumatic brain injury (TBI)?

MOVEMENT DISRUPTERS: Injuries, Accidents
Please list injuries, such as auto accidents, falls, concussions, bike accidents, traumatic events, etc. For each event, please indicate your age and a description of what happened.
Please list fractures and/or surgeries including cosmetic and dental surgeries. For each event, please indicate your age and whether you had a cast, immobilization or any complications.