Client Intake Form 2023
Required Field
Personal Info
First Name
Last Name
Date of Birth (MM/DD/YYYY)
Gender
Male
Female
Identify as
Identify as
Occupation
Contact Info
Mobile Phone
Home Phone
Work Phone
Email
Source of Referral
Address
City
Country
Australia
Canada
Ireland
New Zealand
United Kingdom
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia, Plurinational State Of
Bosnia And Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
C?te D'Ivoire
Cambodia
Cameroon
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic Republic Of The
Cook Islands
Costa Rica
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic Of
Iraq
Isle Of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People'S Republic Of
Korea, Republic Of
Kosovo
Kuwait
Kyrgyzstan
Lao People'S Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States Of
Moldova, Republic Of
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestinian Territory, Occupied
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barth?lemy
Saint Helena, Ascension And Tristan Da Cunha
Saint Kitts And Nevis
Saint Lucia
Saint Martin
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syrian Arab Republic
Taiwan, Province Of China
Tajikistan
Tanzania, United Republic Of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela, Bolivarian Republic Of
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Province / State
Postal / Zip Code
Emergency Contact
Emergency Contact
Emergency Phone
Relationship
Doctor
Doctor's Name
Doctor's Phone
Doctor's Address
Conditions
Energy Level
Fatigue
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High
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Low
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Agitated
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TMJ (Jaw)
Clenching
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Difficulty Chewing
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Difficulty Opening Jaw
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Ear Blockage
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Jaw Pain
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Health Questions
Congenital Heart Defect
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High blood pressure
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Varicose veins
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Depression
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HIV/Aids
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Vertigo
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Diabetes
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Low blood pressure
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Asthma
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Epilepsy
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Migraines/Headaches
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Blood thinner medication
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Gastrointestinal
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Mood Disorder
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Cancer
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Hearing Impairment
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Pacemaker
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Cardiovascular
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Heart Attack
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Past Heart Surgery
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Concussion
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Heart Condition
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Stroke
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Treatment Goals
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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Health Advice for Healing
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Improve Lifestyle
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Improve Symptoms
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Other
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LU/LI (Metal)
Asthma/Allergies
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Grief/Sadness
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Well Being
Exercise
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Interests
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Smoking
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Supplements
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Water Intake
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Caffeine
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Drinking
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Are you currently taking any supplements/Natraceuticals?
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LIV/GB (Wood)
Blurred Vision
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Eczema
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Depression/Stress
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Joints/Neck/Shoulder Pain
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Gall Stones
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Headaches/Migraines
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Insomnia 11pm-3am
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Visual Problems
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Emotion / Memory
Anxiety Disorder
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Stress
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SP/ST (Earth)
Abdominal Pain
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Diarrhea
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Edema (Swelling)
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Indigestion/Heartburn
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Muscles Feel Tired Often
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Nausea/Vomiting
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Energy
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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Female Health
Menopause
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Osteoporosis
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Currently Pregnant
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COVID-19 Questionnaire (Check Appropriate Boxes to Comment Below)
Changes to your medical history since initial intake?
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Willing to wash hands before entering clinic
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Willing to wear face mask in the clinic
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Agree to wear face mask during treatment
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Have you taken precautions to limit exposure
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Have you tested positive for COVID-19?
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To the best of your knowledge, within the last 14 days have you or any other member of your household or support bubble has been exposed to anyone diagnosed with COVID-19 or experiencing COVID?
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Within the last 14 days, have you tested positive for COVID-19 or experienced any COVID-19 symptoms?
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Have you travelled abroad in the last 14 days?
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Have you received a covid alert that you were in close contact with someone with covid, through the covid app in the last 14 days?
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Infectious
Presence of any infectious condition?
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Oncology
Cancer Type
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Date of Diagnosis
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Location
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Vocal Health
Hoarseness
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Complete Loss of Voice
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Whiplash
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Area of Complaint
Neck
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Upper Back
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Mid Back
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Low Back
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Left Shoulder
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Right Shoulder
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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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Sacrum
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Brain Disorders
Bipolar Disorder
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Autism
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Depression
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PTSD
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Acute Stress Disorder
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ADHD
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Anxiety
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Headaches
Headaches
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Sinus
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Tension
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Neurological
Fibromyalgia
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Stroke
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Brain Injury
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Immune
Cancer
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Lupus
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Non-Hodgkin Lymphoma
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Rheumatoid Arthritis
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Gastrointestinal
Digestive Conditions
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Hiatal Hernia
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Crohn's Disease
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Celiac Disease
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Constipation
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Diarrhea
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Irritable Bowel Syndrome
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Stomach Disorder
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Acid Reflux
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Other Gastrointestinal
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Musculoskeletal
Whiplash
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Jaw Pain (TMJD)
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Joint Injury
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Joint Stiffness / Swelling
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Other Musculoskeletal
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Cardiovascular
Blood Pressure
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Heart Condition
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Heart Disease
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High Blood Pressure
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Low Blood Pressure
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Respiratory
Asthma
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Bronchitis
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Emphysema
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Other Respiratory
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Kidney
Bladder Disorder
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Endocrine
Diabetes
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Acute Pancreatitis
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Adrenal Fatigue
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Skin
Acne
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Eczema
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Dry Skin
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Oily Skin
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Sensitive Skin
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Miscellaneous
ADHD
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Autism
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Insomnia
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Loss of Balance
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Vision Loss
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Other Diagnosed Diseases
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Massage Goals
Address Health Issues
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Alternative Therapy
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Balance
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Improve Symptoms
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Increase Well-Being
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Injury Rehabilitation
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Pain Relief
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Stress Relief
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Other
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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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Moderate
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Tension
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Imbalance
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Current Complaint
Pain Severity: 1-10
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Date of Injury?
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Other therapies
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Allergy
Sensitive to scents/essential oils
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Other Allergies
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Emotion / Mood
Mental Abuse History
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Sadness
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Negative Self-Talk
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Stress Response and Coping Strategies
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Anger
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Other Emotions
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Anxiety
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Confusion
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Overall mood and energy level
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Depression
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Physical Abuse History
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Despair
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PTSD
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Fear
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Rate the stress in your life (1-10)
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Grief
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