Home
Therapies
Therapies Overview
Neuromuscular Therapy
Deep Tissue Bodywork
Active Isolated Stretching
Guided Meditations
Overview
Overview of Issues Treated
Understanding Shoulder Pain
Understanding Sciatica
Causes of Lower Back Pain
Understanding Iliacus Dysfunction
Self-Treatment for Iliacus Dysfunction
Role of Fascia in Chronic Pain
Diaphragmatic Breathing
About
About Stephen O'Dwyer
Contact
Online Learning
Home
Therapies
Therapies Overview
Neuromuscular Therapy
Deep Tissue Bodywork
Active Isolated Stretching
Guided Meditations
Overview
Overview of Issues Treated
Understanding Shoulder Pain
Understanding Sciatica
Causes of Lower Back Pain
Understanding Iliacus Dysfunction
Self-Treatment for Iliacus Dysfunction
Role of Fascia in Chronic Pain
Diaphragmatic Breathing
About
About Stephen O'Dwyer
Contact
Online Learning
Medical History Intake Form
All information provided is strictly confidential.
Open Form
Medical History Intake Form
Name
*
First Name
Last Name
Email address
*
Age
Occupation
Present Symptoms: Area/s of greatest discomfort
*
Minor Complaints: Other areas of pain or concern
When did you first notice the present symptom/s?
*
What brought it on?
*
What activities aggravate the condition?
*
Is the condition getting progressively worse?
*
Yes
No
Constant
Comes and goes
Is this condition interfering with your...
*
Work
Sleep
Daily routine
What do you believe is the root cause of the problem?
*
Has there been a medical diagnosis?
*
Yes
No
If yes, what was the diagnosis?
Have you had a similar problem before?
*
Yes
No
If yes, when? What caused those episodes? What relieved them?
Are you on any medications?
*
Yes
No
If yes, please list them:
Alcohol intake
*
Heavy
Moderate
Light
None
Coffee intake
*
Heavy
Moderate
Light
None
Tea Intake
*
Heavy
Moderate
Light
None
Tobacco use
*
Heavy
Moderate
Light
None
Sugar Intake
*
Heavy
Moderate
Light
None
Exercise
*
Heavy
Moderate
Light
None
Are you a vegetarian?
*
Yes
No
Do you feel you eat a well-balanced diet?
*
Yes
No
Are you a shallow breather?
*
Yes
No
Not sure
Have you had any operations/surgeries?
*
Yes
No
If yes, when? Please briefly describe.
Have you had any broken bones?
*
Yes
No
If yes, when? Please briefly describe.
Have you been in an accident or received a whiplash?
*
Yes
No
If yes, when? Please briefly describe.
Please check if you have difficulty with any of the following (there will space at the end of the list to elaborate or clarify):
*
Headaches/migraines
Sinus trouble
Hayfever
Asthma
Loss of taste
Tightness in the throat
Thyroid trouble
Loss of memory
Fatigue
Depression
Head feels heavy
Dizziness
Fainting
Loss of balance
Ringing in ears
Wear glasses/contacts
Light bothers eyes
Muscle spasms in neck
Grating in neck
Tightness in shoulders
Neuritis in shoulders or arms/hands
Cold hands
Chest pain
Shortness of breath
History of heart trouble
High blood pressure
Low blood pressure
Anemia
Nervous stomach
Stomach pain
Ulcers
Lower back pain
Mid-back pain
Upper back pain
Hip pain
Groin pain
Knee pain
Nerves or nervousness
inner tension
Irritability
Cold sweats
Liver trouble
Gall bladder trouble
Indigestion
Intestinal gas
Constipation
Kidney trouble
Bladder trouble
Diabetes
Sleeping problems
Painful joints
Swollen joints
Arthritis
Slipped/herniated disc
Pinched nerves
Swollen ankles
Cold feet
Pain in legs or feet
Pins and needles in arms or hands
Intense menstrual cramps
Jaw tension or pain
Please feel free to elaborate or clarify any of the above or include something not mentioned in this intake form:
Thank you!
