Joel Aumakua

Stretch Therapy & Mobility Training

New Client Intake Form

Personal Information

First Name

Last Name

Email Address

Phone Number

Date of Birth

Gender

Occupation

Street Address

City

State / ZIP

Emergency Contact

Name

Relationship

Phone

How Did You Hear About Us?

☐ Friend/Family☐ Google Search☐ Social Media☐ Yelp☐ Healthcare Provider☐ Gym/Fitness Center☐ Other: ______________

Goals & Activity Level

Primary Goal for Stretch Therapy

Current Activity Level

☐ Sedentary☐ Lightly Active☐ Moderately Active☐ Very Active☐ Athlete

Regular Physical Activities / Exercise

Health & Medical Information

Please check any conditions that currently apply or have applied in the past:

☐ Heart Disease/Condition☐ High/Low Blood Pressure☐ Stroke☐ Diabetes☐ Arthritis☐ Osteoporosis☐ Joint Replacement☐ Fibromyalgia☐ Multiple Sclerosis☐ Cancer☐ Herniated Disc☐ Sciatica☐ Scoliosis☐ Chronic Fatigue☐ Migraines/Headaches☐ Numbness/Tingling☐ Blood Clots/DVT☐ Varicose Veins☐ Pregnancy☐ Recent Surgery☐ None of the Above

Other conditions not listed above

Past Surgeries & Injuries

Please list any past surgeries or significant injuries (include dates if known)

Current Medications

List any medications, supplements, or treatments you are currently receiving

Areas of Discomfort or Tension

Check all areas where you experience pain, tension, or limited range of motion:

☐ Neck☐ Upper Back☐ Mid Back☐ Lower Back☐ Left Shoulder☐ Right Shoulder☐ Left Arm/Elbow☐ Right Arm/Elbow☐ Left Wrist/Hand☐ Right Wrist/Hand☐ Left Hip☐ Right Hip☐ Left Knee☐ Right Knee☐ Left Ankle/Foot☐ Right Ankle/Foot

Please describe any specific pain or discomfort

Pain Assessment

Average Pain Level (0 = No Pain, 10 = Worst Pain)

012345678910

Pain Frequency

☐ Constant☐ Frequent☐ Occasional☐ Rare

Additional Information

Is there anything else you would like me to know before your session?

Acknowledgment

I certify that the information provided above is accurate and complete to the best of my knowledge. I understand that withholding or providing inaccurate information may affect the safety and effectiveness of my sessions. I agree to update this information if any changes occur.

Signature

By signing below, I confirm that I have reviewed and completed this intake form accurately.

Client Signature

Date

Printed Name

Joel Aumakua

Stretch Therapy & Mobility Training

Tampa Bay Area, Florida