Intake Questionnaire

Please answer the following questions.

  • (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.
  • (please be as specific as possible)
  • — e.g. “stand up tall”, “lift the heart”, “shoulders back and down”, etc.?
  • Practitioners working with us and your client, please also the following assessments:

  • (if you know how to assess for intra-pelvic torsion, please do so)
  • This field is for validation purposes and should be left unchanged.