Client Intake Form
Full Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date of Birth
*
-
Month
-
Day
Year
Date
What is your gender?
*
Please Select
Male
Female
N/A
Contact Number
*
Format: (000) 000-0000.
Email Address
*
example@example.com
Emergency Contact Details
*
Name, relationship and phone number
How Did You Find Me?
*
Google, Referral, Facebook, Facebook Groups
Primary reason for visit (please explain)
*
Please include main areas of complaint, pain, tension (please explain)
Check the conditions that apply to you:
*
Asthma
Cancer
Heart disease
Diabetes
Hypertension
Psychiatric disorder
Epilepsy
Headaches
Migrains
Back pain
Neck pain
Shoulder pain
Frozen shoulder
TMJ/Jaw
Pins & needles in arms/hands
Pins & needles in legs
chronic fatigue
Dizziness
Anxiety
Depression
PTSD
Menopausal symptoms
Premenstrual symptoms
Pelvic/hip pain
Numbness in hands
Numbness in feet
Skin problems
Tinnitus
Joint & muscle pain
Ulcers
Fibromyalgia
Hep B/C
Autoimmune condition/s
Low blood pressure
Blood clots
Dental work
Hypoglycemia
Scoliosis
Other
Have you had any other treatments in the past for your current health concern
*
Please list treatments
Are currently pregnant
*
Yes
No
If yes, how far along
*
Please state if there are any complications
Have you had surgery
*
Yes
No
Please give details
*
How recently and please describe stating any complications
Past or recent physical injuries
*
Include fractures or dislocations
Do you have any other physical, neurological or mental health conditions of which I should be aware of
*
If yes please describe
Are you currently taking any medication?
*
Yes
No
List Medication
*
Do you use any kind of illegal drugs or have you ever used them?
Please Select
Yes
No
What kind of drugs? How long have you used/been using them?
How often do you consume alcohol?
Daily
Weekly
Monthly
Occasionally
Never
Signature
Submit
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