Client Intake Form Name Phone ( ) DOB Address City State Zip E-mail: Referred by: Phone ( ) In case of emergency: Phone ( ) Occupation K Male K Female Physician Health Insurance Carrier Please take a moment to carefully read the following information and sign where indicated.. J Yes J No Do you frequently suffer from stress J Yes J No Do you bruise easily J Yes J No Do you have diabetes J Yes J No Any broken bones in the past two years J Yes J No Do you experience frequent headaches J Yes J No Any injuries in the past two years J Yes J No Are you pregnant J Yes J No Do you have tension or soreness in a specific area J Yes J No Do you suffer from arthritis J Yes J No Are you wearing contact lenses Please specify J Yes J No Are you wearing dentures J Yes J No Do you have cardiac or circulatory problems J Yes J No Do you have high blood pressure J Yes J No Do you suffer from back pain J Yes J No Are you taking high blood pressure medication J Yes J No Do you have numbness or stabbing pains J Yes J No Do you suffer from epilepsy or seizures J Yes J No Are you sensitive to touch or pressure in any area J Yes J No Do you suffer from joint swelling J Yes J No Have you ever had surgery Explain below..
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