Clinical Intake - April 2021
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Personal Info
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Emergency Contact
Emergency Contact
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Medical Info
Primary Complaint
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General Health
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Current Treatment
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Past Treatment (from other practitioners)
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Medications
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Additional Info
Insurance Info
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Claims / Benefit
Conditions
LIV/GB (Wood)
Blurred Vision
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Indecisive
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Ringing in Ears
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Depression/Stress
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Insomnia 11pm-3am
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Shoulder/Neck Tension
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Dizziness
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Intermittent Mild Fever
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Teeth Clenching at Night
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Eczema
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Irritability/Anger
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Tension
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Feeling of Lump in Throat
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Joints/Neck/Shoulder Pain
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Visual Problems
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Fullness Below Ribs
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Muscle Cramping/Twitching
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Gall Stones
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Poor Circulation
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Headaches/Migraines
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Red/Dry/Itchy Eyes
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Health Questions
Heart Attack
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Past Heart Surgery
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Cardiovascular
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Heart Condition
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Stroke
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Concussion
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High blood pressure
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Varicose veins
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Congenital Heart Defect
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Low blood pressure
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Vertigo
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Depression
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Meniere Disease
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Warts
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Diabetes
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Migraines/Headaches
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Asthma
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Epilepsy
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Gastrointestinal
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Mood Disorder
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Blood thinner medication
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Hearing Impairment
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Pacemaker
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Cancer
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Treatment Goals
Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Improve Well Being
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Pain Relief
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Rehabilitation
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Stress Relief
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Support in Healing/Recovery
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Other
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HT/SI (Fire)
Skin Rash
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Cysts/Tumor
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Hot Palms/Soles
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Sore Throat
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Dry Scalp
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Insomnia/Sleep Problems
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Itchy/Burning Skin
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Thirst
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Ear Infection
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Lack of Joy in Life
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Easily Startled
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Lymph Swelling
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Excess Joy
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Night Sweats
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Aversion to Heat
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Facial Redness
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Nose Bleed
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Bitter Taste in Mouth
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Gum Problems
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Restlessness/Agitation
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Chest Pain
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Heart Palpitations
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KID/UB (Water)
Decrease Bone Density
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Low Sex Drive
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Emotional Instability
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Poor Memory
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Fear
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Rapid Weight Change
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Bladder Problems
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Feel Cold Easily
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Tendency to Gain Weight
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Brain Foggy
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Hearing Problems
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Thyroid Problems
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Cavities/Tooth Loss
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Hot Flash/Night Sweating
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Urinary Problems
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Weak Leg/Knees
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Craving/Avoiding Salty Foods
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Lack of Bladder Control
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Weakness/Pain in Lower Back
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Dark Under Eyes
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Loss of Hair
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SP/ST (Earth)
Gas/Belching
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Heaviness Anywhere in Body
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Indigestion/Heartburn
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Abdominal Pain
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Muscles Feel Tired Often
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Constipation
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Decreased/Increased Appetite
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Diarrhea
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Fatigue/Worse After Eating
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Well Being
Range of Motion
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Sports
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Exercise
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Hobbies
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Interests
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Mobility/Walking Aids
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TMJ (Jaw)
Ear Blockage
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Ear Pressure
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Ear Ringing
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Ear Stuffiness
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Clenching
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Grinding
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Clicking
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Jaw Pain
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Locking
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Difficulty Chewing
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Morning Stiffness
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Difficulty Opening Jaw
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Energy
When is your energy highest?
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When is your energy lowest?
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Do you struggle with insomnia?
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Does your energy fluctuate?
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How long do you sleep on average?
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Is your energy constant?
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What is your energy level upon awakening?
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Emotion / Memory
Stress
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Male Health
Family History of Prostate Cancer
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Oncology
Cancer Type
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Date of Diagnosis
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Status
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Lymph Nodes Removed
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Medical Devices
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Former Injuries
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Edema
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Blood Clot
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Lymphedema
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Current Tumour
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Enlarged Spleen
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Enlarged Liver
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Vocal Health
Difficulty Swallowing
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Acid Reflux
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Whiplash
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Do you consent to the consultation, assessment and treatment by the therapist?
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Area of Complaint
Neck
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Left Side of Neck
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Right Side of Neck
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Upper Back
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Left Side of Upper Back
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Right Side of Upper Back
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Mid Back
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Left Side of Mid Back
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Right Side of Mid Back
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Low 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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Abdomen
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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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Left Thigh
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Left Calf
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Right Leg
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Right Thigh
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Right Calf
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Left Gluteal
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Right Gluteal
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Left Hip
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Right Hip
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Left Groin
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Right Groin
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Left Knee
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Right Knee
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Left Ankle
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Right Ankle
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Left Foot
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Right Foot
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Sacrum
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Tailbone (coccyx)
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Headaches
Rebound
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Sinus
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Chronic Daily Headache
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Migraines
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Tension
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Headaches
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Cluster
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Other Headaches
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Immune
Rheumatoid Arthritis
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Anaphylaxis
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Hodgkin Lymphoma
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Allergies
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Lupus
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Infectious Mononucleosis
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Leukemia
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Cancer
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CVID
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Non-Hodgkin Lymphoma
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HIV/Aids
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Sjogren's Syndrome
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Other Immune
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Skin
Melanoma/Carcinoma
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Hypersensitive Reaction
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Plantar's Wart
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Melanoma
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Psoriasis
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Rash
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Acne
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Rosacea
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Allergic Dermatosis
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UV Burn
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Athlete's Foot
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Athletes Foot
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Chemical Burn
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Skin Conditions
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Infectious Skin Conditions
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Hypersensitive Reactions
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Bruise Easily
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Skin Irritations
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Cardiovascular
Raynaud Disease
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Heart Attack
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Peripheral Vascular Disease
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Atherosclerosis
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Cold Hands
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Rheumatic Heart Disease
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Phlebitis
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Postural Orthostatic Tachycardia Syndrome
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Cardiac Arrhythmia
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Cold Feet
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Valve Disorders
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Stroke
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Chronic Ischemic Heart Disease
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Cardiovascular Accident
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Blood Pressure
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Swelling
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Chronic Venous Insufficiency
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Pacemaker
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Congenital Heart Defect
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High Blood Pressure
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Heart Disease
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Chest Pain
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Acute Coronary Syndrome
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Myocardial infarction
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Coronary Artery Disease
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Hyperlipidemia
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Low Blood Pressure
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Cardiovascular Conditions
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Blood Clots
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Fainting Spells
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Aneurysm
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Varicose Veins
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Pericarditis
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Congestive Heart Failure
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Lymphedema
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Heart Condition
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Angina
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Other Cardiovascular
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Musculoskeletal
Temporomandibular Joint Dysfunction
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Osteoporosis
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Bone Disease
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Degenerative Disk Disease
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Paget Disease
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Torticollis
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Gout
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Adhesive Capsulitis
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Compartment Syndrome
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Dupuytren's Contracture
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Psoriatic Arthritis
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Sinus Problems
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Ehlers-Danlos Syndrome
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Scleroderma
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Whiplash
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Baker's Cyst
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Dislocation
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Joint Stiffness / Swelling
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Scoliosis
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Artificial Joints / Special Equipment
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Bone or Joint Disease
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Fracture
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Fibromyalgia
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Plantar Fasciitis
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Strain/Sprain
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Jaw Pain (TMJD)
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Broken Bone / Fracture
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Hereditary/Congenital Deformity
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Recti Diastasis
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Muscular Dystrophy
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Arthritis
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Carpal Tunnel Syndrome
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Joint Injury
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Spasms / Cramps
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Myasthenia Gravis
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Tendonitis/Bursitis
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Chronic Fatigue Syndrome
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Osgood-Schlatter Disease
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Osteoarthritis
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Spondylolisthesis
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Ankylosing Spondylitis
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Chronic Myofascial Pain Syndrome
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Osteomalacia
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Other Musculoskeletal
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Neurological
Huntington Disease
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Loss of Sensation
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Dural Ectasia
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Twitching of Face
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Brain Disorder
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Fatigue
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Stroke
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Chronic Pain Disorder
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Fibromyalgia
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Cerebral Palsy
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Numbness
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Brain Injury
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Epilepsy
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Dizziness
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Peripheral Neuropathy
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Parkinsons
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Burning
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Bell's Palsy
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Cerebral Vascular Accident (Stroke)
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Sciatic Pain
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Post Polio Syndrome
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Herniated Disc
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Tingling
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Carpal Tunnel
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Seizure Disorder
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Sleeping Disorders
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Multiple Sclerosis
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Stabbing
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Cerebrospinal Fluid Leak
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Transient Ischemic Attacks (TIA)
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Syringomyelia
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Vertebral and Spinal Cord Injury
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Chiari Malformation
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Tethered Cord
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Cerebral-vascular Accident
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Other Neurological
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Gastrointestinal
Intestinal Gas/Bloating
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Esophageal Disorder
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Stomach Disorders
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Fecal Impaction
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Intestinal Polyps
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Celiac Disease
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Irritable Bowel Syndrome
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Abdominal Hernia
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Constipation
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Poor Appetite
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Acid Reflux
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Diarrhea
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Stomach Disorder
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Adaptive Aids
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Diverticulitis
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Crohn's Disease
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Ulcerative Colitis
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Gastroparesis
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Digestive Conditions
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Eating Disorder
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Hiatal Hernia
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Other Gastrointestinal
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Family History
Respiratory
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Cancer
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Diabetes
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Arthritis
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Cardiovascular
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Kidney
Chronic Kidney Disease
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Congenital Kidney Disease
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Electrolyte Imbalance
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Kidney Stones
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Renal Cysts
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Urinary Incontinence
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Urinary Tract Infection
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Bladder Disorder
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Other Kidney
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Reproductive
Ectopic Pregnancy
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Endometriosis
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Pregnancy
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Menopause
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Gynaecological Conditions
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Menstrual Cycle Disorder
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Ovarian Cysts/Tumors
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Pelvic Inflammatory Disease
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Premenstrual Syndrome
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Breast Disorder
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Uterine Disorder
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Hearing
Vertigo
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Conductive Hearing Loss
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Ear Problems
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Meniere Disease
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Hearing Loss
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Motion Sickness
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Tinnitus
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Other Hearing
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Endocrine
Hypothyroidism
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Prostate Condition
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Diabetes
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Pituitary and Growth Disorder
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Adrenal Fatigue
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Blood Sugar Managed?
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Acute Pancreatitis
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Wound Healing Status?
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Hyperthyroidism
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Other Endocrine
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Blood
Thrombosis/Embolism
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Hepatitis
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Blood Thinner Medication
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Anemia
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Fainting Spells
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Bleeding Disorder
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Stroke
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Hypercoagulability
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Polycythemia
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Haemophilia
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High Cholesterol
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Other Blood
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Respiratory
Respiratory Tract Infection
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Chronic Cough
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COPD
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Shortness of Breath
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Asthma
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Cystic Fibrosis
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Emphysema
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Bronchitis
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Tuberculosis
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Respiratory Conditions
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Infectious Respiratory Conditions
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General Injury Related Questions
What is the next competition/challenge?
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Previous sports-related injuries?
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Treatment of previous injury?
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Physical Therapy
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Chiropractic
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Have you ever had CranioSacral treatment before?
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OTC medications
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Pain medications or steroids
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Surgery (type/year)
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Complications from that injury?
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Miscellaneous
Vision Problems
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Vision Loss
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Mental Health Issues
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Surgical Pins or Wire
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Dental Implants
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Insomnia
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Weakened Immune Function
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Liver Disease
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Other Medical Conditions
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Other Diagnosed Diseases
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Postpartum (check boxes to enter details below)
Any birth/postpartum complications or health issues?
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Any current limitations on your activity?
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Vaginal or cesarean birth?
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Accident Info
Date of Injury
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Which best describes what you are experiencing
Pain
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Mild
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Getting Worse
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Ache
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Moderate
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Staying the Same
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Tension
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Disabling
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Getting Better
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Discomfort
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Constant
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Imbalance
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Intermittent
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Increases with Activity
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Decreases with Activity
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No Change
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Other
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Prescription pain meds Did it help?
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Steroids (oral) Did it help?
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Steroids (injection) Did it help?
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Heat Did it help?
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Cold Did it help?
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Immobilization Did it help?
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Other creams, gels or unguents
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Other therapies
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Physical Activities You Participate In
Pilates
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Waterpolo
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Baseball
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Rugby
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Weight Lifting
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Basketball
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Crossfit
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Running
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Yoga
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Football
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Soccer
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Golf
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Softball
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Hockey
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Swimming
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Lacrosse
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Tennis
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Marathon
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Triathlon
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Other Activities
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Emotion / Mood
Rate the stress in your life (1-10)
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