Symptomatic Client Intake
Client’s Full Name:
Date of Birth:
Secondary or related complaint(s) if any:
Was the Onset : GradualSudden
When did it first occur?
Since the onset, has it gotten : BetterWorse
Has this occured before? YesNo
If Yes, put the # of times :
Describe what caused the pain:
What does your condition prevent you from normally doing?
sitting/drivingwalkingrunninggolfingswimmingweight liftingplaying with childrennormal activities of daily livingother
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.
Please indicate any of the ff. illnesses you have had or currently have:
AllergiesAuto accidentCancerDepressionEating disordersHeart diseaseHigh Blood PressureHIV/AIDSKidney diseaseMental/EmotionalMultiple SclerosisProstate diseaseScoliosisSerious injury/fallSeizuresStrokeUlcerVeneral DiseaseOther
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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