MFR Hands - Client Intake Form

Therapist: Taranjit Grewal | Phone: 713-791-4636 | Email: [email protected]

Note: Please complete this form as thoroughly as possible. All information is confidential and protected under HIPAA regulations. This information helps us provide you with the most effective treatment plan.

Personal Information

First Name *

Last Name *

Date of Birth *

Age

Email Address *

Phone Number *

Street Address

City

State

Zip Code

Preferred Contact Method

Emergency Contact

Emergency Contact Name *

Relationship

Emergency Contact Phone *

Medical History

Primary Care Physician Name

Primary Care Physician Phone

Current Medications

Please list all medications you currently take (include dosage if known):

Medical Conditions

Other Medical Conditions (please describe):

Surgical History

Have you had any surgeries? If yes, please list type and approximate date:

Injuries and Accidents

Have you had any significant injuries or accidents? (falls, car accidents, sports injuries, etc.)

Current Symptoms & Concerns

What is your primary reason for seeking MFR therapy? *

Pain Assessment

Do you currently experience pain?

Yes No

If yes, where do you experience pain? (Check all that apply)

Head / Neck

Shoulders

Upper Back

Lower Back

Hips / Pelvis

Arms / Hands

Legs / Feet

Jaw / TMJ

Chest / Ribs

How long have you experienced these symptoms?

What makes your symptoms better or worse?

Functional Impact

How do your symptoms affect your daily activities? (Check all that apply)

Sleep difficulties

Work performance

Exercise / Physical activity

Sitting for extended periods

Standing for extended periods

Walking or mobility

Household tasks

Social activities

Mood / Mental well-being

Previous Treatments

Have you received any of the following treatments? (Check all that apply)

Myofascial Release Therapy

Massage Therapy

Physical Therapy

Chiropractic Care

Acupuncture

Yoga / Pilates

Injections (cortisone, trigger point, etc.)

Please describe your experience with previous treatments (what helped, what didn't):

Lifestyle Information

Occupation / Daily Activities:

Do you exercise regularly? If yes, what type and frequency?

How many hours of sleep do you typically get per night?

Do you have difficulty sleeping? If yes, please describe:

Goals for Treatment

What are your top 3 goals for MFR therapy? *

What does success look like for you? What would you like to be able to do that you can't do now?

Remote Session Information

Do you have a quiet, private space for remote sessions? *

Yes No

What device will you use for video sessions?

Do you have a stable internet connection?

Yes No

Additional Information

How did you hear about MFR Hands?

Is there anything else you'd like us to know about your health history or concerns?

Acknowledgment and Consent

I certify that the information provided in this intake form is accurate and complete to the best of my knowledge. I understand that this information will be used to provide appropriate myofascial release therapy and will be kept confidential in accordance with HIPAA regulations.

I have read and agree to the MFR Hands Consent for Treatment, Communication, Conditions of Service and Financial Agreement.

Client Name (Print): _________________________________

Signature: _________________________________

Date: _________________________________