Session Intake Form - Somatic Movement Center

All information will be kept strictly confidential. We will discuss your conditions in more detail in person, but filling out this form will allow us to be more efficient and effective during your session.
First and Last Name
Birth Date
Height
Handedness
- Right
- Left
- Ambidextrous
Profession
Daily Activities
List all physical activities or hobbies that you do on a regular basis. For example: computer work, weightlifting, gardening, etc.
Conditions That You Are Experiencing
List or briefly describe all pain and other conditions that you are experiencing.
Have you visited a medical professional to address these conditions? If yes, please describe the diagnosis or outcome.
Medical History
Please list all injuries, surgeries, major illnesses, and medications that you are currently taking.