Intake Form

Client Intake

Name
FirstLast
Address*
Street AddressAddress Line 2CityState / Province / RegionZip / Postal CodeCountry
Home or Mobile Phone*
Additional Phone
Email*
How did you find me?
Have you ever had an Ortho-Bionomy® session?
- Yes
- No
Reason for Your Appointment
- Stress Relief
- Prevention/Maintenance
- Chronic Pain Issue
- Acute Issue/Injury
- Other
Describe what you'd like to address:
When did this situation begin? Do you know the cause?
What part of the body is most problematic?
Describe your discomfort (choose one):
Current Health Status:
Where do you notice your body holding tension?
What things cause you regular stress?
How do you relieve stress?
Health Issue History
- Epilepsy or Seizure Disorder
- Schizophrenia
- Heart attack
- Stroke
- Balance problems
- Panic Attack
In order to keep you safe and meet you where you are right now, it is important to know if you have had any of the health issues listed above.
Personal Stressors
- In the past 3 months
- In the past 6 months
- In the past 12 months
- In the past 3 years
Health challenges and illness sometimes manifest shortly after a major personal stress such as a change in work or money status, moving, marriage, death, illness of a loved one, childbirth, miscarriage, separation or divorce. Has such an event occurred for you in any of the time frames above?
I Have Problems with the Following (Check All That Apply)
- Sleep Issues
- Anxiety or Panic Disorder
- Fibromyalgia
- Arthritis
- Osteopenia/Osteoporosis
- Menstrual Discomfort
- Digestion Problems
- Overactive Bladder
Have you ever been pregnant?
- No
- Yes - not full term
- Yes - vaginal birth
- Yes - C-section
Check all that apply.
What medications are you taking?
Are you seeing a mental health professional?
- No
- Yes
- Yes, but not regularly
Physical Trauma and Injury
- Broken Bones
- Sprains
- Torn connective tissue
- Joint dislocation
- Cranial or Brain injury (concussion, stroke, coma, seizures)
- Fused joints or vertebrae
- Disc injury or surgery
- Whiplash
- Surgery of any kind
- Pins, plates, or artificial joints
Check all that apply
Describe any automobile accidents (including minor ones), falls, or impacts:
Specific Needs and Hopes for Our Work Together
What do you hope to gain from this work?
- Improvement of my physical symptoms
- Pain Relief
- Stress Relief
- Improvement of my emotional/mental state
- Trauma resolution
- Improvement to my body's innate ability to heal itself
- Better proprioception and coordination
- Wellness and overall improved quality of life
Indicate all that apply
Thank You for Letting Me Know About You, And Your Hopes and Expectations

What People Are Saying

“Without this work, I sincerely doubt that I would be where I am today, both emotionally and physically. Her experience and expertise in getting to the root of a problem - and releasing it - has been vital for my well-being. Frankly, I have become spoiled to the point that just any old bodywork will no longer do. The care I have received through Kate is one of the big reasons that I am settling in the Twin Cities - because you just cannot get this everywhere.”
by J. Boudreau

Ortho-Bionomy®,the Sand Dollar design,and Society of Ortho-Bionomy International® are registered trademarks of the Society of Ortho-Bionomy International, Inc. and are used with permission.

Intake Form

Client Intake

Current Health Status:

Specific Needs and Hopes for Our Work Together

Thank You for Letting Me Know About You, And Your Hopes and Expectations

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What People Are Saying