Intake Form
Myofascial Release Therapy - Breana Gilcher, CMT
Basic Information
Full Name
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First Name
Last Name
Contact Number
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Format: (000) 000-0000.
Email Address
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Age
Pronouns
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Occupation
How did you find me?
Reason for seeking treatment
What is your primary issue?
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When did this issue start?
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How does this issue effect you?
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Is this a recurrence of an old injury?
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On a scale of 1-10 (1 being the lowest and 10 being the highest), what is your current level of pain?
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On a scale of 1-10 (1 being the lowest and 10 being the highest), what is the highest level of pain you've experienced with your primary issue?
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What are your goals for Myofascial Release? What would you like to see improve?
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Medical History
Have you experienced any accidents (car accidents, falls, etc.) or bone breaks/fractures?
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Please give dates and describe.
Have you had any surgeries?
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Please give dates and describe.
Are you taking any medications?
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Include prescription and over-the-counter drugs.
What do you do for exercise/physical activity?
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Include type(s) of exercise, sports and activities, and daily movement habits.
Do you, or have you ever, experienced any of the following? Check all that apply.
Circulatory disorder
Asthma
Respiratory disorder
Heart condition
High/low blood pressure
Thrombosis
Dizzyness
Blackouts
Dental complaints
Varicose veins
Diabetes
Bowel complaint
Bladder complaint
Visual disturbances
Allergies
Arthritis
Osteoperosis/osteopenia
Nervous system disorder (MS, stroke, epilepsy)
Headaches or migraines
Ringing in the ears
Eating disorders
HIV/AIDS
Cancer
Pregnancy
MRSA/other bacterial infection, Fungal infection, HSV 1 or 2, Warts, Psoriasis, Eczema
If you checked any of the above, please explain:
An MFR treatment consists of a discussion of your general medical information and specific information regarding your present issue, followed by an in-depth assessment of your presenting issue as well as any other relevant assessments. In subsequent visits, further assessments will be carried out to establish changes to your posture and function and presenting complaint. I understand that my treatment is non-sexual, charges will apply if I give less than 24 hours notice of any cancellation, and that I must inform my therapist if my medical circumstances change at any time.
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I understand and consent.
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