Intake Form Client Intake Personal Information Today's Date Client Name * Client Name First Name First Name Last Name Last Name Date of Birth * Occupation * Gender * MaleFemaleIdentify As Gender Pronouns * Contact Information Mobile Phone * Work Phone Email * Referral Source Address * Address Address Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Emergency Information Emergency Contact Name * Emergency Contact Name First Name First Name Last Name Last Name Emergency Contact Phone * Relationship * Doctor Name * Doctor Name First Name First Name Last Name Last Name Doctor Phone * Doctor Address * Medical Information Primary Complaint * General Health * Current Treatment * Past Treatment (from other practitioners) * Medications * Injuries * Surgeries * Additional Info * Conditions TMJ/Jaw Ear Pressure Jaw Pain Ear Blockage Clicking Difficulty Opening Jaw Locking Difficulty Chewing Clenching Morning Stiffness Ear Ringing Ear Stuffiness Other TMJ/JawOther TMJ/Jaw Well Being Exercise Sports Flexibility Range of Motion Hobbies Other InterestsOther Interests Area of Complaint Left Side of Neck Right Side of Neck Left Side of Upper Back Right Side of Upper Back Left Side of Mid Back Right Side of Mid Back Left Side of Low Back Right Side of Low Back Chest Abdomen Left Arm Right Arm Left Shoulder Right Shoulder Left Elbow Right Elbow Left Wrist Right Wrist Left Hand Right Hand Left Leg Right Leg Left Gluteal Right Gluteal Left Hip Right Hip Left Groin Right Groin Left Knee Right Knee Left Ankle Right Ankle Left Foot Right Foot Sacrum Tailbone (coccyx) Other ComplaintOther Complaint Headaches Rebound Sinus Migraines Chronic Daily Headache Tension Headaches Cluster Other HeadachesOther Headaches Skin Herpes Hypersensitive Reactions Non-Surgical Scars Melanoma/Carcinoma Surgical Scars Pigmentary Disorder Athlete's Foot Plantar's Wart Hyposensitive Reaction/Loss of sensation Acne Bruise Easily Psoriasis Infectious Skin Conditions Allergic Dermatosis Rash Athletes Foot Skin Conditions Rosacea Melanoma Chemical Burn Skin Irritations UV Burn Other SkinOther Skin Neurological Parkinsons Transient Ischemic Attacks (TIA) Numbness Epilepsy Dizziness Herniated Disc Burning Vertebral and Spinal Cord Injury Multiple Sclerosis Tingling Stroke Huntington Disease Cerebral-vascular Accident Brain Disorder Stabbing Chronic Pain Disorder Brain Injury Cerebral Vascular Accident (Stroke) Loss of Sensation Sciatic Pain Cerebral Palsy Seizure Disorder Shingles Other NeurologicalOther Neurological Musculoskeletal Tendonitis/Bursitis Fibromyalgia Hereditary/Congenital Deformity Muscular Dystrophy Spondylolisthesis Joint Injury Jaw Pain (TMJD) Arthritis Osgood-Schlatter Disease Carpal Tunnel Syndrome Ankylosing Spondylitis Degenerative Disk Disease Osteomalacia Osteoarthritis Plantar Fasciitis Bone Disease Osteoporosis Scleroderma Chronic Myofascial Pain Syndrome Compartment Syndrome Gout Scoliosis Sinus Problems Chronic Fatigue Syndrome Dislocation Strain/Sprain Fracture Artificial Joints / Special Equipment Whiplash Amyotrophic Lateral Sclerosis (ALS) Other MusculoskeletalOther Musculoskeletal Cardiovascular Congenital Heart Defect Heart Attack Postural Orthostatic Tachycardia Syndrome Coronary Artery Disease Phlebitis Acute Coronary Syndrome Myocardial infarction Hyperlipidemia Aneurysm Varicose Veins Pericarditis Cardiovascular Accident Blood Clots Angina Raynaud Disease Cardiovascular Conditions Pacemaker Lymphedema Atherosclerosis Rheumatic Heart Disease High Blood Pressure Heart Disease Blood Pressure Cardiac Arrhythmia Cold Hands Valve Disorders Low Blood Pressure Chronic Ischemic Heart Disease Chronic Venous Insufficiency Cold Feet Congestive Heart Failure Other CardiovascularOther Cardiovascular Respiratory Chronic Cough Shortness of Breath Respiratory Tract Infection Asthma COPD Emphysema Cystic Fibrosis Bronchitis Respiratory Conditions Infectious Respiratory Conditions Tuberculosis Other RespiratoryOther Respiratory Blood Bleeding Disorder High Cholesterol HIV/AIDS Hypercoagulability Polycythemia Haemophilia Thrombosis/Embolism Hepatitis HIV Anemia Other BloodOther Blood Family History Arthritis Cardiovascular Respiratory Other FamilyOther Family Immune Non-Hodgkin Lymphoma Cancer Hodgkin Lymphoma Infectious Mononucleosis Rheumatoid Arthritis Leukemia Anaphylaxis Lupus Allergies Other ImmuneOther Immune Gastrointestinal Crohn's Disease Diverticulitis Irritable Bowel Syndrome Ulcerative Colitis Other GastrointestinalOther Gastrointestinal Miscellaneous Dental Implants Autism Vision Problems Dental Bridge Vision Loss Music Preference Hearing Impaired Visually Impaired Loss of Balance Mental Health Issues Dentures Surgical Pins or Wire Insomnia ADHD Liver Disease Other Medical ConditionsOther Medical Conditions Other Diagnosed DiseasesOther Diagnosed Diseases Agreements & Consent Facility Privacy Policy (Review Required) The privacy of your personal information is important to our facility. We are committed to collecting, using and disclosing personal information responsibly and only to the extent necessary for the goods and services we provide. Like all healthcare professionals, we collect, use and disclose personal information in order to serve our clients. The primary purpose for collecting personal information is to provide treatment. Like most organizations, we also collect, use and disclose information for purposes secondary to our primary purposes. The most common examples of our related and secondary purposes is to invoice clients for goods or services that was not paid for at the time, to process credit card payments or to collect unpaid accounts. Clients or other individuals we deal with may have questions about our goods or services after they have been received. We retain client information for a mandatory minimum of ten years after the last contact. YOU CAN LOOK AT YOUR INFORMATION With only a few exceptions, you have the right to see what personal information we hold about you. We can help you identify what records we might have about you. We will also try to help you understand any information you do not understand (e.g., short forms, technical language, etc.). We reserve the right to charge a nominal fee for such requests. Privacy Policy Agreement * I have reviewed and agree to the Privacy Policy above. Liability Waiver (Review Required) In consideration of my use of the exercise equipment, facilities, and manual therapy/massage provided by Core Fitness & Bodywork, LLC, I expressly agree and contract, on behalf of myself, my heirs, executors, administrators, successors and assigns, that the company and its insurers, employees, officers, directors, and associates, shall not be liable for any damages arising from personal injuries (including death) sustained by me, or my guest in, on, or about the premises, or as a result of the use of the equipment or facilities, regardless of whether such injuries result, in whole or in part, from the negligence of the company. By the execution of this agreement, I accept and assume full responsibility for any and all injuries, damages (both economic and non-economic), and losses of any type, which may occur to me or my guest, and I hereby fully and forever release and discharge Core Fitness & Bodywork, LLC., its insurers, employees, officers, directors, and associates, from any and all claims, demands, damages, rights of action, or causes of action, present or future, whether the same be known or unknown, anticipated, or unanticipated, resulting from or arising out the use of said equipment and facilities. I expressly agree to indemnify and hold Core Fitness & Bodywork, LLC, harmless against any and all claims, demands, damages, rights of action, or causes of action, of any person or entity, that may arise from injuries or damages sustained by me or my guest. I agree to comply with all rules imposed by Core Fitness & Bodywork, LLC regarding the use of the facilities and equipment. I agree to conduct myself in a controlled and reasonable manner at all times, and to refrain from using any equipment in a manner inconsistent with its intended design and purpose. I understand and acknowledge that the use of exercise equipment involves risk of serious injury, including permanent disability and death. I understand and agree that Core Fitness & Bodywork, LLC is not responsible for property that is lost, stolen, or damaged while in, on, or about the premises. Liability Waiver Agreement * I have read the foregoing waiver and release of liability and voluntarily executed this document with full knowledge of its content. Facility Policy & Procedures (Review Required) ATTIRE Proper athletic attire must be worn while in private or group sessions. Sneakers, socks, athletic pants/shorts, and t-shirts are considered appropriate attire. Jeans are not permitted. Jeans often have studs, rivets and zippers which may tear the fabric on the benches.Bare feet or sandals are NOT permitted (except during certain group exercise classes). During winter months and rainy days, please bring a dry pair of shoes. You are more than welcome to leave a pair of shoes at the studio, in the cubbies or lockers. CANCELLATIONS Any cancellation with less than 24 hours notice will be charged the full rate of the missed session. Your missed appointment is another person's missed opportunity. Exceptions include illness and inclement weather. HEALTH AND SAFETY If you have the flu, a cold, or any other contagious illness, please do not attend sessions, as having a contagious illness puts you and all other members at risk. Illness causes an individual's system to become weaker and the likelihood for injury increases significantly when training under these conditions. Furthermore, given the nature of physical training, the transmission of contagious diseases occurs quite readily. Disinfectant wipes are available for cleaning perspiration from the cardio equipment, pads, and benches. Please be courteous of fellow members and use the supplies provided in the areas that you use. INCLEMENT WEATHER Text messages or phone calls will be made to the numbers on file, at least an hour before scheduled sessions regarding cancellations due to inclement weather. EQUIPMENT USAGE PROCEDURES Cardio equipment is on a first come, first serve basis. Please limit use to 30 minutes, while people are waiting. Please wipe down cardio equipment after use. ALL other equipment is not permitted to be used without supervision. TRAINING/BODYWORK One of the benefits at Core Fitness & Bodywork is being able to substitute a training session for bodywork, or vice versa, if need be. However, please note that the current rates for each session will apply. Facility Policy & Procedure Agreement * I have read the Facility Policy & Procedures and agree to the terms layout above. Signature signature keyboard Clear Submit If you are human, leave this field blank.
