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
Pain Assessment
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☐ Constant☐ Frequent☐ Occasional☐ Rare
Additional Information
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.