1-1 INTAKE QUESTIONNAIRE

Hi!

Please fill out this form and submit at least 24 hours before our session together. This way, I can be as prepared as possible and can make the best use of our time together.

Feel free to take notes during our session. Know that I take notes during our time together, too.

You only need to fill out the questions below that apply to you. Feel free to write as much or as little as you’d like. Although, the more I know, the better!

I look forward to our time together.

Jamie

First Name

Last Name

Birthday

Profession

Address

Phone

*If you’re running late, please call, text or email me. My email is info@movementtherapyco.com. My number is 303 809 3988. If you need to re-schedule please do so 24 hours in advance unless its an emergency. If you don’t cancel with 24 hours notice, and it’s not an emergency, I have to charge the full amount of our session together. Thank you for your understanding.

What is the particular aspect of your fitness and health you would like to focus on or need help with?

If you have an injury or are in pain, please describe, to the best of your ability, the pain, discomfort or physical issue:

If you’re in pain, on a scale of 1 - 10 (10 being most pain), please rate your level of pain:

How long have you had this issue, and how/when did it begin? Please include information regarding an accident or trauma (physical or emotional)

Is there any movement or form of exercise in particular that makes you feel better?

Is there any movement or form of exercise in particular that makes you feel worse?

What exercise(s), if any, are you doing now, and how often?

To the best of your ability, please describe the environment, and activities you spend most of your day doing (i.e: sitting at a desk, standing/walking waiting tables)

Is there any other info you think would be useful for me to know?

If you have Arthritis, where is it, and what kind?

If you have Osteoporosis, where is it?

Date

I confirm that the information given in this form is true

Thank you for your submission! Click here to download a copy of this form.

Yoga . Fitness . Pilates . Movement Therapy . Posture

Movement Therapy Company

1-1 INTAKE QUESTIONNAIRE

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