Client Intake Form

Please mention expectations, objectives
Please mention location, type of sensation (dull, sharp, moves around?), history, when it's worst in the day, and any beliefs about the causes
What are you movement / exercise goals or dreams?
Please also list diagnoses and allergies if any
Please mention frequency
Please mention modality
Please rate your level of knowledge on pain mechanisms
Please rate the extent to which you feel fulfilled in life
Please rate the extent to which you feel socially supported
I understand this therapy involves therapeutic physical contact from which I can withdraw my consent from at any time
I am interested in receiving dry needling and would like to discuss the risks and benefits