Client In-Take Form
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1
2Georgia LaCroix
Client In-Take Form
General Information
Name
Date of birth
Today’s date
Street address
Occupation
Home phone
City/State/Zip
E-mail
Work phone
Emergency contact and phone
Referred by
Cell phone
Health Care Information
Primary health care provider
Other provider and modality
Telephone
Telephone
Current diagnosis or treatment
Current diagnosis or treatment
May I consult with your health care provider(s) if/when you and I feel it would be helpful? Please initial: Yes____ No____
Current Medications
(prescription, over-the-counter, and herbal)
Personal Medical History
(Please (Circle) conditions experienced with the last 12 months and (Underline) older conditions; please
indicate where in your body you are experiencing the condition.
Skeletal
broken/fractured bone _________
bursitis __________
arthritis _________ tendonitis _________
osteoporosis_________
other _______________
Muscular
sprain/strain ________
spasm/cramp ________
headache
neck/shoulder/arm
low back/hip/leg
jaw (TMJ) \ fibromyalgia
lupus
other _______________
Circulatory
heart condition ________
high/low blood pressure
varicose veins
blood clots _______
edema ______
lymphedema ______
phlebitis _______
other _______________
Digestive
constipation
diarrhea
gas/bloating
diverticulitis
irritable bowel syndrome
indigestion/reflux
ulcer
other _______________
Nervous System
numbness/tingling ________
chronic pain ________
herpes/shingles
headache
migraine
fatigue
sleep disorder
carpal tunnel
multiple sclerosis
Parkinson’s
other _______________
Skin
allergy ________ rash ________ warts ________
athlete’s foot
plantar-wart
other _______________
Reproductive
Pregnant ______ stage _______
PMS
other _______________
Client In-Take Form - Page 1of 2
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