Client Intake Form

First Name

Last Name

Phone/Mobile

Address

Address Line 1

Address Line 2

City

State

Zip Code

Country

Date of Birth

Profession

Hobbies/Interests

Client History

Please take the time to fill out this form as accurately as possible so we can best address your needs. All information will be kept strictly confidential.

Describe your muscle pain. Where is it located? Is it chronic? How long have you had it?

Do you experience any tingling or numbness? If so, where?

Are you hypersensitive to sound, touch, smell, or light?

Please list any accidents, injuries, major illnesses, or surgeries you’ve experienced as far back as you can remember.

What treatments have you tried for your pain? Which ones have been beneficial?

Do you have any prior experience with Somatics Education? If so, how? Why?

Are you currently on any medication? If so, what?

Are you currently under the care of a physician? If so, what is their diagnosis?

Do you fall asleep easily at night?

Yes

Sometimes

Do you feel rested when you wake up?

Yes

On a scale of 1-10, with 1 = Poor and 10 = Excellent. Please rate the following:

Quality of Sleep

Stress Level at Work

Stress Level at Home

Are there activities or hobbies you can no longer do because of your pain or limited movement? How has pain changed your life or the way you are living? Please explain.

What is your main goal for this session? Why is this important to you?

Why is it important for you to move well? How will moving well change your life and the lives of those around you?

Is there anything else you would like to share at this time with me?