Name

First Name

Last Name

Email Address

Phone

(###)

###

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Age

What would you say your goal is for our time together?

List your current & previous health conditions? Please include medical diagnoses, surgeries, accidents, injuries, etc., and approximate dates.

How long has your current health issue been going on?

Who else are you currently seeing for your health concerns or general health promotion? How often do you see them?

Please state the areas of discomfort in your body. Try to describe where they are located and type/degree of discomfort.

What are your favorite physical movements? Least favorite? Do you have a regular exercise program? Please describe?

Where do you hold tension in your body?

Do you do a lot of Sitting, Driving, Standing, Desk work, Lifting, or Lying down?

What relieves your pain? What increases your pain? Think about ranges of motion, movements etc.

Do you experience stress, anxiety, sadness or depression? Are there places in your body where these feelings tend to dwell when they come up?

Is there anything else I should know about your body or health history?

Private Session Intake