Structural Restoration Intake Form
Please complete this form to help us provide you with a safe and personalized experience.
Full Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phon
*
Please enter a valid phone number.
Format: (000) 000-0000.
Health & Safety Screening
Under care of a physician/PT/chiropractor?
Yes
No
Please describe
Are you currently pregnant?
Yes
No
Medications
Pain & Discomfort
Areas of discomfort
Back
Neck & shoulder
Hip
Knee
Hand, wrist & foot
General stiffness
Other
Please describe
How long
Discomfort scale (1–10)
Please Select
1
2
3
4
5
6
7
8
9
10
What makes it better/worse
Past injuries/surgeries
Lifestyle & Activity
Typical day
Exercise/activity
Yoga experience
Please Select
None
Some
Regular practitioner
Sleep quality
Please Select
Good
Fair
Poor
Stress level
Please Select
Low
Moderate
High
Goals
What would you like to get out of sessions
Anything else Amir should know
Acknowledgment
Health conditions
Recent fracture/surgery
Unstable spine
Osteoporosis
Blood clot
Uncontrolled blood pressure/heart condition
Active infection/fever
Neurological condition
Hypermobility
Disc herniation
Diabetes
None of the above
Submit
Should be Empty: