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.

There are five (5) pages; you can save at the end of each to come back to finish them later.

You are finished when you reach the SUBMIT option.

Thanks, and see you soon!

Full Name

First NameLast Name

Parent Name (if under 18 years old)

First NameLast Name

Cellphone Number

Email

example@example.com

Date of Birth

Date

Today's Date

Date

Referred by

First NameLast Name

What are your goals?

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)?

What's happened to you--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.