Client Intake Form
Please take the time to fill out this form as accurately as possible so I can most appropriately address your needs. All information submitted on this form will be kept strictly confidential.
Name *
Email *
Phone *
Profession
Describe your muscle pain. Where is it located? Is it chronic? How long have you had it?
Please list any accidents, injuries, major illnesses, or surgeries you’ve experienced (even back to your childhood years).
Please list the various treatments you’ve already sought for your pain. Which ones have been beneficial?
Are you under the care of a physician? If so, what is his/her diagnosis of your pain condition?
Are you currently on any medication?
Are there any activities or hobbies (i.e. running, yoga, gardening, etc.) that you can no longer do because of your pain?
Do you fall asleep at night easily? Do you wake up feeling rested?
What is your goal for this/these session(s)? What would you like to get out of Clinical Somatics?
How did you hear about Clinical Somatics?
Any further information you would like to add.
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