PERSONAL INFORMATION
Date of Birth:
Date of Birth:
PAIN & INJURY
Describe the reason for your visit (e.g if it's for a specific injury, chronic pain etc).
Note your expectations and goals if you having, e.g to climb the stairs without being in pain or the ability to drive pain-free
Do you have or have you ever had: *
Are you currently taking any medication? *
Please describe any in the past or in recent history.
Please describe any notable injuries, operations and accidents; also note if you are currently injured.
Note down any conventional or alternative treatments you've had.
How do you rate your pain today?
Please refer to the Universal Pain Assessment Tool
Whether you were delivered naturally, via C-Section, forceps etc. If you don't know, please leave blank.
e.g falling off a bike and hitting your head, if you wore braces to straighten out your teeth, verrucas, anything you can remember - past experience forms who we are today.
Whether it was unassisted, a C-Section, forceps, induced etc
Do you walk your dog on the same side most days?
Do you carry a bag mainly on one shoulder?
Do you sleep on the same side of the bed most nights?
Day-to-day I have a lot of energy:
Day-to-day I feel stressed:
My work shoes are uncomfortable:
My job is stressful:
THE SMALL PRINT
Medical/Liability Waiver *
I am fully aware that the services I wish to receive are those of a holistic nature and do not serve as a substitute for professional medical advice, examination, diagnosis or treatment. I understand the information I have been given to be the truth and consent to the treatment of Anatomy in Motion and will inform Frances of any changes to my medical status if they have changed since completing this online form. I understand that if I have been untruthful with my details or have failed to give enough relevant information any treatment could be adversely affected. Frances does not claim to cure or to diagnose any medical condition in the same regard as a physician, as her opinion is that of a holistic, complementary and alternative therapist and her professional opinions, advice, examinations and recommendations do not constitute the medical advice of a doctor/physician.
Privacy Policy *
We do not share any of your information with any third parties or profit from your personal information and data. Our privacy policy can be found at the bottom of each page.
Declaration of consent: *
I have completed this form to the best of my ability and knowledge and agree to inform Frances if any of the above information changes at any time.
Please write your name or initials in the box below. By signing this form electronically you are agreeing to the terms and conditions herein.
Date Today: *
Date Today:
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Pain & injury form

Thank you for doing the following:

• Completing this form at least TWO DAYS in advance of the date of your session to allow time to prepare.

• Use the Universal Pain Assessment tool to measure your current pain level.