Client Intake Form

Please fill out this form before your first session.

First name

Last name

Phone

Billing Address (required for insurance)

Birthday

Year

Month

Day

Emergency Contact Name

Emergency Contact Phone

Health Insurance Company

Stress Scale Today? (Please give it a score from 1 to 10; 10 being the highest level)

Occupation & Activities/Hobbies

Are you currently seeing a medical professional?

Are you taking any medications, aspirin, ibuprofen, herbs or supplements?

Water intake per day?

Coffee intake per day?

Soft drinks per day?

How are you feeling today?

Please describe the condition/problem for which you are seeking relief.

Are you receiving other treatments for the above condition? (Physio, massage, chiro, etc.)

Are there any movements or activities that bother you in particular?

Please list all accidents, surgeries, falls, and scars below. (Even old ones)

How did you hear about Time to Heal? (Friend, social media, Google search, etc.)

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