Comprehensive Intake Form
We come from a clinical standpoint so please take your time and give us some detailed answers. This will help us serve you best. We may chose to call you for further details or do some additional research before your first visit so we can best serve you.
Please briefly describe who you are and what you do: What does a week in your shoes look like?
Emergency contact and phone
Medications or supplements and why you are taking them:
Do you suffer from recurrent pain or did you suffer an injury? Please explain.
What helps or worsens your discomfort?
Are you currently on-top of your self care? What do you do for you?
Please check any conditions that may apply:
Carpal or Cubital Tunnel Syndrome
Sprains or Strains
Tingling or numbness
High/Low blood pressure
Headaches or migraines
What is your email?
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