Intake Form

* Required fields
Name *
E-mail Address *
Address
City
Province/State
Country
Postal Code
Home Phone
Office Phone
Cellular Phone
Occupation
Emergency Contact Name & Phone
Birthdate
Age
Height
Weight
Relationship Status
Referred by
Main Work Activities
Daily Computer Usage (hours per day)
Previous Bodywork Experience (frequency & outcomes)
Carpal Tunnel
Rheumatism
Gout
Back Pain
Skin Disorder
Neck Pain
Shoulder Pain
Knee Pain
Arm Pain
Wrist Pain
Overuse Injury
Whiplash
Bone Fractures
MVA
Sports Injury
Stress
Arthritis
RA
Osteo arthritis
Musculo-Skeletal Explanation (if needed)
Physician Name & Phone
Therapist Name & Phone
Reason for the Visit
Start Date of Symptoms
Past/Present Treatments (for reason for visit)
Current Medication
Supplements
Complementary Therapies
Water Daily Intake
Caffeine Daily Intake
Alcohol Daily Intake
Tobacco Daily Intake
Excercise Routine
Vision
Glasses/Contact Lenses
Smell
Hearing
Taste
Depression
Eating Disorder
Mood Swings
Substance Abuse
Emotional/Psychological Comments (if needed)
AIDS/HIV
Lymes Disease
Allergies
Mononucleosis
Fatigue
Cancer
Cancer Type (if applicable)
Fever (chronic)
Herpes
Herpes Type (if applicable)
Fibromyalgia
Fungal Infections
Fungal Infections Type (if applicable)
Auto-Immune Explanation (if needed)
Adrenal Insufficiency
Hyperthyroid
Hypothyroid
Pituitary dysfunction
Endocrine Explanation (if needed)
PSA Levels
Epilepsy
Insomnia
Dizziness
Migraines
Neurological Explanation (if needed)
Earaches (chronic)
Jaw Pain
Headaches
Ear/Nose/Throat Explanation (if needed)
Angina
Hypertension
Heart Attack
Stroke
Heart Failure
Cardio-vascular Explanation (if needed)
Constipation (chronic)
Jaundice
Diabetes
Liver Disorder
Diarrhea (chronic)
Ulcers
Gastritis
Flatulence
Hepatitis
Pancreas
Hypoglycemia
Digestion Explanation (if needed)
Bladder Infection
Kidney Stones
Urinary Explanation (if needed)
STD
Type of STD (if applicable)
Miscarriages
# of Miscarriages (if applicable)
Endometriosis
Abortion
# of Abortions (if applicable)
Pregnancies
# of Pregnancies (if applicable)
Reproductive Explanation (if needed)
Chicken Pox
Mumps
Measles
Whooping Cough
German Measles
Scarlet Fever
Major Illnesses Explanation (if needed)
Please list any injuries you had and have presently
Please list any surgeries you had or know you will have
Please list any traumatic, or life treatening events that occurred in your life, and when they happened:(Ex.: Separation, divorce, depression,deaths or other significant event)
What do you hope for and what are your expectations from this healing today and long-term?
What is your connection with spirituality?
General (Further details on reason for visit or anything else you want to share or want me to know)


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