Intake Questionnaire

Name*

First Last

Email*

Phone

How did you hear of us?

1. Your Age:

2. Do you have any background in anatomy and/or kinesiology? NOTE: We ask this question to know whether we can use anatomical terminology in the Findings Report. We work mostly with people who have no background in either, so no worries if you do not.

Yes
No

3. Please list injury/pain /surgery history in chronological order.

(approximate dates are fine) NOTE: More is better in this case. Even if you think a previous injury is not pertinent to your current complaint, please include. For example: every ankle sprain, falling off your bike as a child, concussions, etc.

4. Primary complaints (describe your pain) and movements or positions that trigger your pain.

(please be as specific as possible)

5. Scar locations (c-sections and episiotomies count)

6. Do you have postural cues for yourself, and if so what are they?

— e.g. “stand up tall”, “lift the heart”, “shoulders back and down”, etc.?

7. Divide your feet into inside / outside / front / back. You will end up with four quadrants on each foot: inside-front, inside-back, outside-front, & outside-back. Stand up and take a moment to determine where you feel you are weight bearing on your feet. It may help to close your eyes. Where do you weight bear?

8. Do you have any issues with elimination — e.g. incontinence, constipation, urgency, frequency, etc.?

9. What does a typical week looks like in terms of physical activity (e.g. walk a lot, sits at a desk, etc.)?

10. What type of exercise do you do if any?

11. Pertinent medical findings — if you have had imaging or a previous diagnosis, please share along with the name of the practitioner.

12. What have you tried to get better (e.g. chiropractic, etc.)? How did it go?

Practitioners working with us and your client, please also the following assessments:

1. Static postural assessments of pelvis, ribs, and skull in all planes.

(if you know how to assess for intra-pelvic torsion, please do so)

2. Facing of talii.

3. Forefoot varus.

4. Any other assessment notes:

Phone

This field is for validation purposes and should be left unchanged.

Intake Questionnaire

Please answer the following questions.

Practitioners working with us and your client, please also the following assessments: