Client Intake Form Barrelogic Page 2
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1
2
3Health History
Medications: ___________________________________________________________________
Please check the following conditions that apply to you, past and present. Please add your comments to clarify the
condition using the back of this form.
Client Initials: __________
Musculo-Skeletal
Skin
Nervous System
___ Headaches
___ Rashes
___ Numbness/Tingling
___ Joint Stiffness/Swelling
___ Allergies
___Twitching of face
___ Spasms/Cramps
___ Athlete’s Foot
___ Fatigue
___ Broken/Fractured bones
___ Warts
___Chronic pain
___ Strains/Sprains
___ Moles
___ Sleep disorders
___ Back, hip pain
___ Acne
___ Ulcers
___ Shoulder, neck, arm, hand pain
___ Cosmetic surgery
___ Paralysis
___ Leg, foot pain
___ Other: __________________
___ Herpes/Shingles
___ Chest, ribs, abdominal pain
___ Cerebral Palsy
___ Problems walking
Digestive
___ Epilepsy
___ Jaw pain/TMJ
___ Nervous stomach
___ Chronic Fatigue Syndrome
___ Tendonitis
___ Indigestion
___ Multiple Sclerosis
___ Bursitis
___ Constipation
___ Muscular Dystrophy
___ Arthritis
___ Intestinal gas/Bloating
___ Parkinson’s disease
___ Osteoporosis
___ Diarrhea
___ Spinal Cord injury
___ Scoliosis
___ Diverticulitis
___ Other: ___________________
___ Bone or joint disease
___ Irritable bowel syndrome
___ Other: ___________________
___ Crohn’s Disease
Other
___Colitis
___ Loss of appetite
Circulatory and Respiratory
___ Adaptive aids
___ Forgetfulness
___ Dizziness
___ Other: ___________________
___ Confusion
___ Shortness of breath
___ Depression
___ Fainting
Reproductive System
___ Difficulty concentrating
___ Cold feet or hands
___ Pregnancy
___ Alcohol use: _____________
___ Swollen ankles
___ Current
___ Nicotine use: _____________
___ Pressure sores
___ Previous
___ Caffeine use: _____________
___Varicose veins
___ PMS
___ Hearing impaired
___ Blood clots
___ Menopause
___Visually impaired
___ Stroke
___ Pelvic Inflammatory Disease
___Burning upon urination
___ Heart condition
___ Endometriosis
___ Bladder infection
___ Allergies
___ Hysterectomy
___ Eating disorder
___ Sinus problems
___ Fertility concerns
___ Diabetes
___ High blood pressure
___ Prostate problems
___ Fibromyalgia
___ Low blood pressure
___ Other: ___________________
___ Post/Polio Syndrome
___ Lymphedema
___ Cancer
___ Other: ___________________
___ Infectious disease: _________
________________________
___ Surgeries: ________________
________________________
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Parent category: Business