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