New Client Intake Form
In which Logan Kinei Service are you interested?*
Do you live on Cape Cod year 'round?*
Do you have pain or injury?*
Describe pain and/or injury*
Please list other health care providers you see
Do you participate in any exercise or fitness?*
Is your pain or injury auto or work related? *
Please describe why you seek help/guidance:*
If you have any, are your issues:*
How did the issue(s) begin?*
Have you had this issue before?*
What daily activities are being affected?*
What are your goals/intentions for this?*
Please rate your pain TODAY *
Please rate your pain at BEST *
Please rate your pain at its WORST*
Location of your pain - please provide detail!*
Do you smoke cigarettes? *
Do you take any medications?*
Do you consider yourself active?*
If yes, please provide job title and duties:
How would you rate your overall health?*
If yes, please describe surgeries (including date
Bowel or bladder problems
Is there anything else you would like us to know?