New Client Intake Form Page 2
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2Have you ever seen a Naturopathic doctor? ______________________________________________________
Have you experienced any kind of bodywork before (i.e. massage, acupuncture, etc.)? If yes, what type? ______
Do you wear any type of supportive braces anywhere? _____________________________________________
Do you wear orthotics? __________ If yes, for how long? __________________________________________
What percentage of your day is spent sitting? __________, standing? ___________, driving? ______________
Are your symptoms worse at the end of the workday? ______________________________________________
Does your work station give you support and encourage good posture? ________________________________
How would you rate your own posture? _________________________________________________________
Medical History
Please list any recent injuries, illnesses, or surgeries: ______________________________________________
__________________________________________________________________________________________
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Are you currently under the care of a physician? Yes________ No________
If yes, please explain.
__________________________________________________________________________________________
List current medications, including aspirin, ibuprofen, etc. __________________________________________
__________________________________________________________________________________________
Please check all that apply
____
Cancer
____
Hi/Low Blood Pressure
____
Epilepsy
____
____
____
Digestion Problems
Elimination Problems
Ulcers
____
____
____
Cancer: Type _____
Respiratory Problems
Cold Hands/Feet
____
____
____
Migraines/Headaches
Sinus Problems
Heart Problems
____
Back Problems
____
Neck Problems
____
Bruise Easily
____
Sciatica
____
Arthritis/Bursitis
____
Allergies
____
____
____
Stroke
Immune Disorder
Fibromyalgia
____
____
____
Scoliosis
TMJ
Carpal Tunnel
____
____
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Osteoporosis
Tendonitis
Asthma
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Diabetes
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Now Pregnant
____
Immovable Joints
Do you have any chronic or frequent pain? ______________________________________________________
Have you had any accidents, auto or other? ______________________________________________________
Have you ever had any major surgeries? _______________________________________________________
Have you ever had a head injury? _________ Have you noticed dizziness? ______ Change in hearing? _______
Change in vision?_____________
Are there any other medical conditions the therapist should be aware of? ______________________________
Are you pregnant? _____ If yes, how far along are you? ___________________________________________
The above information is accurate and true to the best of my knowledge. If there are any changes in my current
level of health, I will inform the person here that I’m seeing of my condition. I understand that this office does
not diagnose or treat illness or disease and does not prescribe medications. I agree to pay my account with this
office in accordance with the regular rates and payment terms. If, for any reason cancellation is necessary, I will
give a 24-hour notice. I understand that if I do not give this notice, I will be charged for the appointment unless
it can be filled. Emergency cancellations will be determined by owner. It is agreed that any claim of liability is
hereby waived.
_________________________________________ _______________________________________________
Signature
Date
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