Intake Form

Please fill this form out prior to your first appointment.

All information is submitted through a secure, encrypted connection.

Date

First name

(If you are the Guardian and the appointment is for your child, please fill out using your child's first name)

Last name

Phone (add "1" before your area code)

Address Line 1

Address Line 2

City

State

ZIP Code

Birthday

Occupation

Hours Worked Per Week

Emergency Contact

Emergency Contact Phone (add "1" before your area code)

General statement about your health & primary concerns at this time

What are your major health goals, from a big-picture perspective?

What has worked before to help you move closer towards your goals?

What has not worked before?

What would success look like to you in 3-6 months, if we were to work together?

Please indicate & Describe any areas of Pain / Discomfort from the Diagram at the end of the form, below

ONSET: How did it start? (Sudden Trauma, Gradual, etc)

DURATION: How long have you had this issue?

FREQUENCY: How often does it bother you? (Rarely, Always, etc)

TYPE: What does it feel like? (Sharp, Dull, Broad, Tingling, Radiating, etc)

SEVERITY: How bad is the pain? (1-10 scale, or Mild / Moderate / Severe)

Please list ALL major injuries, surgeries, hospitalizations, and major illnesses from childhood until now that you can remember.

Have you had any Head Injuries, Concussions, Whiplash? When?

Have you had any Broken bones, Fractures, major sprains? When?

Have you had any Dental Surgeries, Dental Work, Orthodontics, etc? When? Any side-effects?

Do you ever have symptoms of Dizziness, Vertigo, or Motion Sickness? When?

Do you wear glasses or contacts? Have you had vision surgery? When?

Do you have tattoos or other scars not listed above? How many? When? Body Location?

Are you currently pregnant? If so, how many weeks?

Do you engage in physical activity on a regular basis?

What sports & activities did you like or play as a child?

What sports & activities do you like to participate in as an adult?

Are you, or were you, a competitive athlete? What sport?

Please list all prescription medications, nutritional supplements, and herbs/botanicals you are currently taking (include the medication name, date started, dose, frequency, and reason you take them).

Anything else you'd like to share that may be applicable to the sessions?

Are you willing to commit 20-25 minutes per day, split over several "mini-sessions" to make lifestyle changes and work towards your goals? (This is the minimum requirement that we've seen be effective).

How did you hear about us?

Pain & Discomfort Diagram