New Client Intake Form
Name*
Today's Date*
Birthday *
Age*
Gender/How You Identify
Email*
Phone Number*
Address
Do you live on Cape Cod year 'round?*
Yes
No
Emergency Contact Name*
Emergency Contact Phone Number*
Emergency Contact Email*
Height (ft/inches)
Weight (lbs)
Do you have pain or injury?*
Yes
No
Onset date of pain and injury
Describe pain and/or injury*
Please list other health care providers you see
Do you have access and use a fitness facility?*
Do you participate in any exercise or fitness?*
Yes
No
Please describe why you seek help/guidance:*
If you have any, are your issues:*
Getting Better
Staying the same
Worsening
How did the issue(s) begin?*
Have you had this issue before?*
Yes
No
What daily activities are being affected?*
What are your goals/intentions for this?*
Please rate your pain TODAY *
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Pain You Can Imagine -- Emergency!
Please rate your pain at BEST *
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Imaginable Pain - Emergency!
Please rate your pain at its WORST*
0 - No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Imaginable Pain -- Emergency!
Location of your pain - please provide detail!*
Rate your sleep:*
Excellent
Good
Average
Poor
Horrible
On average, how many hours do you sleep per night*
Do you smoke cigarettes? *
Yes
No
Do you drink alcohol?*
Yes
No
Do you take any medications?*
Yes
No
Please list medications:
How many days a week do you exercise?*
Do you consider yourself active?*
Yes
No
Do you work?*
Yes
No
If yes, please provide job title and duties:
How would you rate your overall health?*
Excellent
Good
Ok
Fair
Poor
Please check all you have or have had:
Hypertension
Check the box if true
Cardiac pacemaker
Check the box if true
Cardiac conditions
Check the box if true
Vertigo
Check the box if true
Dizziness
Check the box if true
Vision Problems
Check the box if true
Kidney Problems
Check the box if true
Bowel/Intestinal Issues
Check the box if true
Mental Health
Check the box if true
Stress
Check the box if true
Anxiety
Check the box if true
Depression
Check the box if true
Metal Implants
Check the box if true
Currently Pregnant
Check the box if true
Circulation Issues
Check the box if true
History of Blood Clots
Check the box if true
Speech Problems
Check the box if true
Osteoporosis
Check the box if true
Arthritis
Check the box if true
Diabetes
Check the box if true
Stroke
Check the box if true
Seizures
Check the box if true
Fractures
Check the box if true
Cancer
Check the box if true
None
Check the box if true
Other
Have you had surgery?*
Yes
No
If yes, please describe surgeries (including date
Please check if you've had any in the past year?
Chest pain
Check the box if true
Heart palpitations
Check the box if true
Cough
Check the box if true
Self doubt
Check the box if true
Shortness of breath
Check the box if true
Difficulty walking
Check the box if true
Joint pain or swelling
Check the box if true
Night pain
Check the box if true
Difficulty sleeping
Check the box if true
Loss of apetite
Check the box if true
Nausea/Vomiting
Check the box if true
Bowel or bladder problems
Check the box if true
Fever/Chills/Sweat
Check the box if true
Headaches
Check the box if true
Hearing problems
Check the box if true
Highly Stressed
Check the box if true
Coordination problems
Check the box if true
Weakness in arms or legs
Check the box if true
Loss of balance
Check the box if true
Is there anything else you would like us to know?
In which Logan Kinei Service are you interested?*
Logan Kinei Guide | Remote | Single Session
Logan Kinei Guide | Remote | Monthly Or Yearly
Logan Kinei Guide | Remote | Yearly Subscription
Logan Kinei | Private In-person | Single Session
Logan Kinei | In-person | Package Or Subscription
Email & Text Consultation Subscription