Egoscue Method Client Intake Form
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1Egoscue Method
Client Intake Form
®
Client:_____________________________________________________ Date:______________
Current Symptoms
Level 1-10
(please include severity on 0 to10 scale: 0 – no pain, 1-3 – mild, 4-6 – moderate, 7-9 – severe,
10 – disabling, the worst pain ever experienced by you)
1.___________________________________________________________________________
2. ___________________________________________________________________________
3. ___________________________________________________________________________
4. ___________________________________________________________________________
5. ___________________________________________________________________________
Occupation:
___________________________________________________________________________
Do you have any health issues?
__________________________________________________________________________
Are you currently on any pain or other medications?
___________________________________________________________________________
What position, if any, increases your pain?
___________________________________________________________________________
What position, if any, decreases your pain?
___________________________________________________________________________
Do you have favorite exercises (if any)?
___________________________________________________________________________
Do you have trouble sleeping due to pain?
___________________________________________________________________________
What time of day do you have the most pain?
___________________________________________________________________________
Do you feel better or worse with movement?
___________________________________________________________________________
What kind of exercise or activities are you involved in?
___________________________________________________________________________
What is your primary reason for joining this program?
___________________________________________________________________________
Short-Term Goal(s):
___________________________________________________________________________
Long-Term Goal(s):
___________________________________________________________________________
Time willing to invest in menu:
___________________________________________________________________________
What time is best for your menu? AM
PM
Split
Any
Pre/Post Activity
Type of Learner: Auditory
Visual
Kinesthetic
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Parent category: Business