Rooted Manual Therapy

Client Intake Form

Please complete this form before your first visit. It helps us make the most of your time together.

Don't fill this out:

Contact Information

Full Name

Date of Birth

Today's Date

Phone

Email

Emergency Contact Name

Emergency Contact Phone

Reason for Visit

What brings you in? Describe your primary areas of concern.

When did this start, and is there anything that makes it better or worse?

Health History

Please check any that apply to you:

Heart condition High or low blood pressure Diabetes Cancer (current or history) Pregnancy Blood clots or DVT Osteoporosis Arthritis Numbness or tingling Seizures Skin conditions or allergies Recent surgery

Current medications

Anything else we should know?

Acknowledgment

I confirm that the information above is accurate to the best of my knowledge, and I will inform my practitioner of any changes to my health history in future visits.

Type your full name as your signature

Your information is sent directly to Rooted Manual Therapy and is not shared elsewhere.

Thank You

Your intake form has been received. We'll see you soon.