RETURNCLIENT-SessionIntakeQuestionnaire

Jessica N. Ferrer, LMT at PhysiotherapyBoston.com
70 Cross Street, Unit B (front)
Winchester MA 01890

www.physiotherapyboston.com
(781) 369-5352

*And Satellite Office location(s) and Outcall
Returning Client
Session Intake Questionnaire
In addition to answering the REQUIRED segments of this questionnaire relevant to your upcoming appointment, complete any non-required segments with new or updated information since your last visit so that the Provider may keep your records as current as possible. Thank you.
Returning Client's Full Name*
Date of Birth*

MonthDayYear
Date
Telephone (Best)*
Telephone (Other)
Current Occupation
If you have a new job, we would LOVE to know!
Best Email Address to Contact you*
example@example.com
List any current Allergies or Sensitivities for the Provider to be aware of for this upcoming session*
Type "NONE" if nothing to update since last visit
Emergency contact/relationship
Emergency contact phone
Goals for the upcoming scheduled bodywork/massage session (check all that apply)*

pain managementmaintain healthreduce stressgeneral relaxationreduce discomfortpre-operative soft tissue manipulationfacilitate post-operative recoverykinesiology tapingOther
Please list any/all specific areas of the body you would like today's session to be focused on:
List any new medications and/or supplements which you are taking and their corresponding conditions since last session. *
Type "NONE" if nothing to update since last visit
What Professional Bodywork or Therapy have you received since your last session with this Provider (e.g. physical therapy, chiropractic, osteopathic care, energy work, etc)*
Type "NONE" if nothing to update since last visit
What is your CURRENT exercise routine (personal sports routines, fitness classes, personal training, coaching, etc)*
List all physical discomforts/complaints relevant for this Provider to be aware of and consider in treatment planning for your upcoming session*
Type "NONE" if nothing to update since last visit
Once received, your Provider will review your completed Questionnaire and may ask secondary questions for more detail at the start of your appointment.

By submitting this form, I attest that the information provided is true, accurate, and complete to the best of my knowledge.
Today's Date*

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty: