Intake Form

Intake Form

Please complete as thoroughly as possible in order to assist us in our treatment
client name*

First NameLast Name
Pain Chart

Please draw your pain as accurately as possible in RED using the mouse.
What is your pain level today?*

1

2

3

4

5

6

7

8

9

10

1 is lowest, 10 is highest
What is your major problem today?*
Contact Info
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Birthdate

MonthDayYear
Date
Referred by
Emergency contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
Is this your first session Body Coaching Session?
How did you hear about us?
Medical History
height
weight
Are you currently under the care of a physician?
If yes, what for?
Are you currently under the care of an alternative medicine practitioner?
If yes, what for?
Are you currently under the care of a chiropractor?
If yes, what for?
Please select any of the following that apply to you (in the past or currently).

arthritisblood clotsosteoarthritisspinal problemsrespiratory problemssurgeryback problemsrecent breaks/sprainsvaricose vienscirculatory problemsneurological problemssinus problemsheart problemsdiabetesdigestive problemsdisc problemsmajor illness or diseasepacemakeraccidents or injurieshigh blood pressurejoint problemsheadachesepilepsy or seizuresconstipationpregnantskin problemswear contactsspinal stenosisscoliosisthyroid problem
Do you use any other body therapies?

chiropracticphysical therapytens unitsmassageacupunture
What do/did you use therapy for?
How much water do you drink per day?
List any food allergies:
Do you wear orthotics?
If so, how long have you worn them?
Did you prefer to sit on one leg as a child?
List any medications you currently take:
List any medications you have used in the past and why you stopped taking it:
Pain History
Describe any pain/tension. How long have you had it?
Was there an event or illness that seemed to start it?
Is your pain/tension worse in the morning or evening?
Does anything seem to change your pain? Make it worse/better?
Are there any particular movements associated with your pain?
Please list any accidents/surgeries, etc starting with the most recent (date/accident).
Jaw/Facial Pain
Do you have TMJD (Temporomandibular Joint Dysfunction)?
Do you have jaw pain associated with chewing or yawning?
Do you clench or grind your teeth?
Do you wear a night guard?
When was your last dental appointment?
Do you wear bifocals or progressive lens?
Do you or have you ever experienced any visual disturbances?
If yes, please explain:
When was your last eye doctor appointment?
Life/General
Rate the level of stress in your life as you perceive it?

HighMedium HighMediumMedium LowLow
What are your goals regarding your overall quality of life?
Home Stress
Do you have child-care or other home responsibilities?
Are you immobile for long periods of time?
Do you lie on the couch or bed and read?
Work Stress
Are you able to work?
How do you feel after a day of work?
Does your pain affect your work?
What is your occupation?
Does you perform repetitive movements at work?
Are you immobile for long periods of time?
Given the opportunity, what would you like to do?
Activities/Hobbies
List any activities/hobbies you do on a regular basis and how frequently you do them:
Exercise
Are you able to exercise?
What type of exercise do you do and how frequently?
What type of exercises do you think you would enjoy doing?
Do you stretch regularly?
If yes, what stretches? When?
Sleep
How many hours of sleep do you typically get?
Do you experience any of the following?

difficulty falling asleepwaking oftenwaking unrefreshed
What position(s) do you most often sleep in?

backsidestomacharms overheadhalf stomach/half sidefetal positionspooningwith pets
If you sleep on your back, do you put pillows under your knees?
If you sleep on your side, do you put pillows between your legs?
If you sleep on your side, do you put pillows at your chest?
Alcohol/Tobacco/Caffeine/Sugar
Do you drink alcohol?
If yes, what kind and how often?
Do you smoke or use tobacco products?
If yes, what kind and how often?
Do you drink caffeinated beverages?
If yes, what kind and how often?
Do you frequently eat foods with high amounts of sugars and carbohydrates?
If yes, what kind and how often?
If you have any additional files you would like to share with us, including a photo release or x-rays, please do so here.

Cancelof
Consent for NeuroMuscular Coaching.

I understand that the purpose of NeuroMuscular Coaching is for restoring the body’s pain-free movement and that it is not meant to diagnose or treat any illness, disease or any other physical or mental disorder, injury or condition. I have informed my NeuroMuscular Coaching practitioner about my state of health and any recommendations and restrictions on the part of my medical doctor or therapist insofar as bodywork is concerned. I understand that if I cancel a session less than 24 hours in advance I will be billed for the session.
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Intake Form

Pain Chart

Contact Info

Medical History

Pain History

Jaw/Facial Pain

Life/General

Home Stress

Work Stress

Activities/Hobbies

Exercise

Sleep

Alcohol/Tobacco/Caffeine/Sugar