Client Intake Form
Patient Data
Patient Name
First Name
Last Name
Age
Occupation
Gender
Please Select
Male
Female
Phone Number
Format: (000) 000-0000.
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Emergency Contact Person
First Name
Last Name
Emergency Contact Phone Number
Format: (000) 000-0000.
Relationship to the Patient
Medical / History Data
Do you have any of the following conditions?
Hypertension
Heart issues
Rashes
Diabetes Mellitus
Bone problems
Blood Clooting
Spams/Cramps
Sprains
Varicose Veins
Constipation
Arthritis
Seizure
Spinal Cord Issues
Are you wearing any eye contact lenses?
Yes
No
Are you pregnant, breastfeed, or nursing? (Female)
Yes
No
Are you smoking? If yes, how many packs a day?
Are you wearing any implantable medical devices? If yes, what are these devices?
Are you currently taking any medications? If yes, please list them below:
Were you previously hospitalized? If yes, please indicate when and why:
Did you undergo any surgery in the past? If yes, please indicate the name or location of the surgery:
How do you manage stress? Please elaborate:
Authorization
I confirm that all information given in this form is true, complete, and accurate.
I released this organization for any responsibility in case of accident, illness, or injury.
I acknowledge that no assurance was offered about the outcome.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature of the Patient
Parent/Guardian Name
First Name
Last Name
Signature of Parent/Guardian
Print Form
Submit
Submit
Should be Empty: