New Client Intake Form

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New Client Intake Form
Name: _____________________________________
Date: ______
Referred By: __________________
Phone – Work: ______________________________
Address: ___________________________________
Phone – Home: ______________________________
City/State/Zip: ______________________________
Birthday: __________________________________
Mobile: ____________________________________
Occupation: ________________________________
E-Mail: ____________________________________
Emergency Contact: __________________________
Phone: _____________________________________
General Information:
What is your main reason for coming to therapy? __________________________________________________
What specific goals would you like to achieve from therapy? ________________________________________
__________________________________________________________________________________________
How and when did the symptoms begin? ________________________________________________________
Where are your symptoms located? Please mark the areas on the figures below:
How long have you had these symptoms?
_____________________________________________________________
Are you currently, or have you ever been, under medical supervision for this problem?
______________________
__________________________________________________________________________________________________
Have you had any tests for this problem; such as x-rays, MRI or CT scans?
________________________________
Describe the symptoms. Please check all that apply:
□ Dull
□ Ache
□ Burning
□ Sharp
□ Periodic
□ Constant
□ Sore
□ Stiff
□ Numb
□ Tingling
What makes it better or worse?
______________________________________________________________________
__________________________________________________________________________________________________
On a scale of 0 to 10 with 10 being the most severe imaginable discomfort, what is your discomfort level right
now? _____________________________________________________________________________________
What time of day is the pain worse? ___________________________________________________________
Do you have trouble sleeping? If yes, what position do you sleep in? __________________________________
Physical Factors:
What physical activities are you currently involved in? _____________________________________________
Do you stretch now? ________________________________________________________________________
Do you feel flexibility is an important part of fitness? ______________________________________________
Have you ever had chiropractic treatment? If yes, how long, how often and with whom? ___________________

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