Medical Intake Form Complete this quick form to help us tailor your session. // Step 2: Personal Details Please provide your personal details. All information is kept confidentialDate of birth *Enter your date of birth (dd/mm/yyyy)Step 3: Main Concerns Tell us about your pain/discomfortWhere would you like us to focus?Select all areas you are experiencing discomfortNeckShouldersUpper BackLower BackArms / HandsHips / Legs / FeetHead / MigraineDigestive systemOtherHow severe is your pain or discomfort?0 – No pain1–3 – Mild (annoying but manageable)4–6 – Moderate (interferes with daily activities)7–9 – Severe (hard to function)10 – Worst imaginable painDuration of symptomsLess than 2 weeks2–6 weeks2–6 months6–12 monthsMore than 1 yearStep 4: Medical History Please answer honestly so we can provide safe and effective treatment.Serious car accident? *YesNoPlease provide details (date, type of injury, treatment if any) *Have you had surgery (orthopedic or other)? *YesNoPlease give details *Have you undergone radiation, chemical, or iodine treatments? *YesNoPlease give details *Are you currently using any medication? *YesNoPlease list here *Do you have any chronic illnesses? *YesNoPlease give details *Is there any other health condition or information your therapist should know about?Final DetailsHow did you hear about us?SelectFamily/friendInstagramGoogle search/Google MapsReturning clientOtherConsent and Agreement *I confirm that the information I provided is true and complete to the best of my knowledge. I understand that treatments provided are complementary and do not replace medical care, and I agree to proceed voluntarily.YesFinish and Continue to Booking