Adult Functional Health Intake Form

Please fill in all of the information below honestly and to the best of your ability.

This information will be kept strictly confidential as per ....

When you get to the bottom of each page, click NEXT until you reach the end where leave your signature. Thank you!

Full Name

First Name Middle Name Last Name

Do you have physical pain or discomfort?

Yes No

Describe WHERE your pain or discomfort is:

Check ALL that apply to your pain or discomfort:

Please rate the severity of your pain at its WORST

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Worst Pain Ever

Please rate the severity of your pain at its BEST

	1	2	3	4	5	6	7	8	9	10

1 is No Pain, 10 is Worst Pain Ever

What do you think is the CAUSE of your pain or discomfort?

Is there anything else you can describe to me about your pain or discomfort?

Please Print out the following diagram and use the following colour code to illustrate your pain:

red = BURNING | blue = SHARP | yellow = NUMBNESS/ TINGLING/ SHOOTING

CIRCLE = areas of RESTRICTION or STIFFNESS

PLEASE PRINT THIS DIAGRAM AND BRING IT TO YOU WITH YOUR NEXT APPOINTMENT. :)

Do you have any difficulty with movement?

Never or Rarely Yes - Occasionally Yes - Often

If yes, please describe:

Have you had recent diagnostics or imaging done for the above complaints? (X-rays, MRI's, Cat Scans, etc.)

Yes No on a waitlist

Have you had any surgeries related to the above complaints?

No Yes On a waitlist

If Yes, please describe the type of surgery, reason, and date (month and year):

List all THERAPIES you have tried and their success for the above complaints (physio, yoga, chiro, exercise therapy, supplements, etc.)

Empower Health PAIN & MOVEMENT Questionnaire

My signature below affirms that I have answered the above as truthfully and completely as possible: