Intake Form

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

Referred By

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)

Confirm and Submit