Client Intake Form

Referred By:

Past medical history (previous injuries, accidents, surgeries, etc.) Please describe and include approximate dates:

What daily activities are you finding difficult or are limited because of your above complaints?

What are your health goals from BodyTalk?

Describe the problem(s) for which you seek help. Please include the dates when each problem occurred.

List medications (including over the counter) you are presently taking:

Have you ever had this problem before? If so, when?

Please list any other kind of healthcare professional you are seeing for this/these problem(s):

Please list any medical tests you have had within the past year:

How much time do you have for yourself to relax and what do you do to relax, ie: hobbies, meditation, etc?

Do you exercise? And if so, how often?

How many hourse a night do you sleep?

Is your sleep restful? If not, please explain.

When do you feel at your best physically, mentally, emotionally and/or spiritually?

Can you remember a time in your life when you would have described your state of health as a 10? If so, what words would you use to describe what that felt like?

If you have any pain in your body, please list the location(s) and give that pain a grade on a scale of 1 – 10. (1 = awareness, 10 = extreme)

Please indicate your current stress levels

Please rate the following on a scale of 1-10 (1 = poor, 10 = excellent)