JLM Therapeutics Initial Assessment

JLM Therapeutics LLC

Client Intake Form
1633 Fillmore Street, Suite 114

Denver, Co 80206 | 720-935-9980

www.jlmtherapeutics.com
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City

Postal / Zip Code
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
How Did you Hear About Us? *

Website Social Media Groupon/ClassPass/Living Social Walk By Referral - please note who referred you
Referred By
Side Dominance *

Right Left
Preferred Pronouns *

He/Him/His She/Her/Hers They/Them/Theirs
Emergency Contact Name *

First Name Last Name
Emergency Contact Phone *
Please enter a valid phone number.
Emergency Contact Relationship *
Occupation *
Have you had massage and/or yoga therapy in the past? *

Yes No
If yes, how recently and how often?
What are your physical goals for today’s session? What are your mental/emotional goals as well, if any? *
What are the top three places on your body you want to address in our time together? *
What sort of massage pressure do you prefer? *

Light/Swedish Medium/Deep Tissue Medium/Ashiatsu Hard/I want to feel sore the next few days
Do you practice yoga? *

Yes No
If yes, what sort of yoga do you practice?
How do you sleep in general? *
How are you feeling today? *
Health Conditions

Please check the category and mark any conditions plus list treatments for those conditions. Use the body diagram to mark areas of past physical ailments, injuries and surgeries as well as any muscle and/or joint pain, stiffness, numbness, tingling, swelling, bone breaks, sprains, strains, skin bruising, sensitivity, rashes, or infections
Structural - include details on the body diagram below

arthritis osteopenia osteoporosis scoliosis broken bones dislocations surgeries injections acne skin rashes boils abscesses herniations implants infections sprains discomfort/pain edema neuropathy rashes infection cancer
Please Show Any Areas of Concern (Pain, Surgery, Etc)
Reproductive

pregnancy period endometriosis prostate enlargement testicular pain penis pain painful intercourse pelvic floor dysfunction infections cancer
Digestive

Crohn’s IBS diabetes gas bloating constipation diarrhea intestinal polyps kidney disease infections incontinence cancer
Circulatory

heart disease arrhythmia arteriosclerosis pacemaker stint shunt stroke varicose veins blood clots infections high/low blood pressure cancer
Respiratory

asthma COPD/emphysema smoking infections COVID cancer pneumonia
Neurological

Sciatica MS Parkinson’s Fibromyalgia epilepsy seizures headaches migraines dizziness memory loss confusion overwhelm infections cancer
Ocular

Lasik glaucoma farsightedness infections nearsightedness retinal detachment pink eye cancer
Endocrine

edema allergies thyroid testosterone estrogen adrenaline infections cancer swollen lymph nodes
Psychosocial

anxiety depression loneliness constantly active agoraphobia alcohol recreational drug use pharmaceutical drug use non-recreational drug use
Is there any condition not listed above or information you think I should know in regard to your health, your progress or your care?
Should be Empty:

JLM Therapeutics LLC

Health Conditions