Client Intake Form Fill out this form to help me personalize your treatment and don’t forget to hydrate after your appointment! Today's Date MM DD YYYY Referred By Name * First Name Last Name Email * Phone (###) ### #### Date of Birth MM DD YYYY Weight Sex Male Femal Occupation Current Physician Medications you are currently taking and why? Supplements you are taking and why? Current Symptoms What's your treatment history? Regular Physical activity or Sports History of Accidents or Injuries Head Trauma Emotional Trauma Last X-ray/MRI/CT Scan Exercise Sleep pattern Diet Habits (Alcohol, drugs, smoking) Have you taken steroids for joint injections or an allergic reaction? Family Health problems Surgeries Describe your concern? * How did you hear about us? Referral Google Search Social Media Word of mouth By my signature I am stating that the above is true and accurate of my current physical and mental condition on this date. (At your appointment, you will be asked to sign this form.) Thank you!
