Online Client Intake Form
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Personal Info
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Emergency Contact
Emergency Contact
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Relationship
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Medical Info
Primary Reason for Seeking Treatment
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Any Current Treatments?
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Past Treatment (from other practitioners)
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Medications
Injuries- Past or Present that may affect the treatment
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Additional Info
Conditions
COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Have you experienced any Covid-like symptoms in the past 48 hours?
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Area of Complaint
Left Side of Neck
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Right Side of Neck
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Left Side of Upper Back
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Right Side of Upper Back
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Left Side of Low Back
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Right Side of Low Back
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Chest
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Left Arm
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Right Arm
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Left Shoulder
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Right Shoulder
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Left Elbow
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Right Elbow
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Left Wrist
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Right Wrist
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Left Hand
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Right Hand
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Left Leg
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Right Leg
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Left Hip
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Right Hip
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Left Knee
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Right Knee
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Left Foot
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Right Foot
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Headaches
Migraines
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Headaches
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Chronic Daily Headache
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Tension
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Neurological
Sciatic Pain
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Loss of Sensation
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Herniated Disc
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Cardiovascular
Cardiovascular Conditions
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Varicose Veins
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Blood Clots
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Blood Pressure
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Reproductive
Pregnancy- Please note # of weeks and any complications
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Musculoskeletal
Strain/Sprain
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Tendonitis/Bursitis
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Artificial Joints / Special Equipment
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Fracture
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Arthritis
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Jaw Pain (TMJD)
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Scoliosis
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Plantar Fasciitis
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Whiplash
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Skin
Athlete's Foot
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Rash
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Bruise Easily
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Skin Irritations
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Plantar's Wart
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Miscellaneous
Surgical Pins or Wire
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Other Medical Conditions
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Music Preference?
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