Symptomatic Client Intake
Date:
Client’s Full Name:
Full Address:
Date of Birth:
Phone:
Your Email
Male Female
Age:
Chief Complaint
What Hurts:
Secondary or related complaint(s) if any:
Was the Onset : Gradual Sudden
When did it first occur? Since the onset, has it gotten : Better Worse
Has this occured before? Yes No If Yes, put the # of times :
Describe what caused the pain:
What does your condition prevent you from normally doing? sitting/driving walking running golfing swimming weight lifting playing with children normal activities of daily living other If other, put it here:
What is your long-term goal from treatment (e.g. play a round of golf without pain)?
Please list any major illnesses, injuries, hospitalizations, accidents, or surgeries.
Date————Injury/Illnesses/Surgery——————————Treatment——————–Results
Please indicate any of the ff. illnesses you have had or currently have:
Allergies Auto accident Cancer Depression Eating disorders Heart disease High Blood Pressure HIV/AIDS Kidney disease Mental/Emotional Multiple Sclerosis Prostate disease Scoliosis Serious injury/fall Seizures Stroke Ulcer Veneral Disease Other If other, state it here:
Manual therapy and rehabilitative exercise contain the inherent risk of sprain, strain, fracture and dislocation. By signing below you acknowledge under no duress that you understand and accept this risk.
The Stay Active Clinic is an open setting. This means your rehabilitative exercise and manual therapy are performed in the open while being visible to others. All care is taken to be discrete and you are free to request a private setting whenever you wish. By signing below you acknowledge and accept the statements above.
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New Client Initial Exam Form