Initial Intake form for working with Lila Heller.
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Question 1 of 25
First and Last Name
Question 2 of 25
Question 3 of 25
Question 4 of 25
Question 5 of 25
Question 6 of 25
Question 7 of 25
Emergency Contact Name
Question 8 of 25
Emergency Contact Number
Question 9 of 25
Goals for training session (e.g., manage pain, relieve discomfort, maintain health, reduce stress, athletic performance, etc.)
Question 10 of 25
Current areas of discomfort/pain/injury
Question 11 of 25
Please Identify & Describe Any Areas Of Discomfort:
Question 12 of 25
Question 13 of 25
How did it start? (Sudden Trauma, Gradual, Etc)
Question 14 of 25
Duration: How long have you had the problem?
Question 15 of 25
Frequency: How often does it bother you? (Rarely, Always, etc.)
Question 16 of 25
Type: What does it feel like? (Sharp pain, tingling, weakness, tightness, etc.)
Question 17 of 25
Severity: How bad is the pain? (Mild, Moderate, Severe)
Question 18 of 25
Please list previous injuries (fractures, sprains/strains, etc) and prior surgeries:
Question 19 of 25
Current medications and supplements:
Question 20 of 25
Professional bodywork previously received (e.g., physical therapy, chiropractic, osteopathic care, etc.)
Question 21 of 25
What is your current exercise routine? How long (duration of time spent exercising), how often (how many days a week), what kind?
Question 22 of 25
What did/do you love to do? What form/s of physical activity bring you the most joy?
Question 23 of 25
If you were to sum up your life as it is right now in three words, what would they be?
Question 24 of 25
Please list any other information you think I should know, and or concerns or additional questions you may have.
Question 25 of 25
Your Physician's Name (if applicable)