Client Intake Form Full Name Email Phone Occupation Marital Status Married Single Date of Birth Do you have a diagnosis from a physician? If so, please describe your current course of treatment. Are you taking any medications at this time? Yes No If so, please list your medications. Please list any past medical conditions, illnesses and surgeries. Main Complaint? Please explain briefly. Do you receive pain relief from medications at this time? Yes No Is there any time of the day or night that you always experience pain or discomfort? Yes No If so, please explain: How is your sleep? Please select the areas of your life that the pain or discomfort has interfered: Work Social activities Emotional well being Sex life Family responsibilities Sleep Daily living activities Exercise Other areas not listed above What type of exercise or physical activities do you participate in and at what frequency? What do you do when you are in pain to feel better? What makes the pain worse? Please check the areas of your body where you experience pain: Head Neck Shoulders Chest Hands Wrists Abdomen Upper back Mid back Lower back Hips Knees Feet Buttocks Please include anyone areas of the body not mentioned above and if you checked any areas of your body above, please indicate the type of pain - sharp pain, burning, numbness or dull ache What is your stress level? Do you know your triggers? What tools or practices do you currently employ to help manage your stress? Main Goal? If you didn't have this current issue what could/would you do? Have you had any experience with Yoga? Please include any additional information here that you believe would be important for me to know. Submit
