intake form

Basic information

Full name

Phone

Date of birth (optional)

Preferred appointment location

Reno Truckee

Reason for initial visit

Where is your body talking to you?

Accidents, surgeries, and medical history

Include joint replacement if applicable. Please include dates if known.

Allergies & hypersensitivities

Please tell us about any allergies or hypersensitivities

Current medications

List current medications and the conditions they are treating

Expectations

What are your expectations from this work?

Client understanding and consent

Please read and check each box to confirm your understanding.

I understand that my pain and concerns are often the result of a lifetime of how I have moved and not moved, including adaptations and compensations that developed in response to pain, such as limping.

I understand that these sessions are intended to help stuck or restricted soft tissue regain natural, healthy movement.

I also acknowledge that this work is a process, that my body’s response over time helps determine the appropriateness and direction of care, and that this process may take several visits.

I understand change may be gradual and can vary from session to session. Progress is influenced by my individual history, nervous system adaptation, and ongoing movement habits. I acknowledge that no specific outcomes can be guaranteed.

Both boxes are required to submit this form.

Signature

Type your full name as your signature

Date