Tania Hughes Wellness Intake Form
General Intake Information
FULL NAME *
PREFERRED NAME
PHONE (PREFERRED) *
PHONE (SECONDARY)
EMAIL *
ADDRESS (STREET, CITY, STATE, ZIP) *
DATE OF BIRTH *
MM
/
DD
/
YYYY
OCCUPATION *
EMERGENCY CONTACT (RELATIONSHIP, NAME, PHONE) *
REFERRED BY (Name, Flyer, Ad, website, etc.) *
ARE YOU TAKING ANY MEDICATIONS? *
LIST ANY MEDICATIONS
ARE YOU CURRENTLY PREGNANT? *
IF PREGNANT: HOW FAR ALONG? ANY RISK FACTORS?
DO YOU SUFFER FROM CHRONIC PAIN? *
IF YOU SUFFER FROM CHRONIC PAIN, WHAT MAKE IT BETTER/WORSE?
HAVE YOU HAD ANY ORTHOPEDIC INJURIES? *
DESCRIBE ANY ORTHOPEDIC INJURIES
INDICATE ANY OF THE FOLLOWING THAT APPLY TO YOU *
Required
DESCRIBE ANY CONDITIONS INDICATED ABOVE
How do you rate your current level of physical activity? *
On a scale of 1-10, (1 is lowest, 10 is highest) how would you rate your level of stress? *
LOWEST
HIGHEST
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