Intake Form

Name *

Date *

Current Symptoms (include onset and duration)

1

Pain Level (1-10)

1.

Symptom 2

2.

Symptom 2 pain level

2.

Symptom 3

3.

Symptom 3 pain level

3.

Symptom 4

4.

Symptom 4 pain level

4.

Do you have any health issues? *

Are you currently on any pain or other medications? *

What position, if any, increases your pain? *

What alleviates your pain? *

Do you have trouble sleeping due to pain? *

What time of day do you have the most pain? *

Do you feel better or worse with movement? *

What kind of exercise or activities are you involved in? *

What is your primary reason for starting postural alignment therapy? *

Short-Term Goal(s): *

Long-Term Goal(s): *

Have you had success relieving pain with any therapies? If so, please describe: *

How much time are you willing to invest in therapeutic exercises at home? *

Submit

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