Intake form

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I'm looking forward to working with you! By sharing the following information, you and I will be better able to address your goals and needs. Just answer them as best you can if you don't remember exact dates. Injuries from childhood can impact our bodies later in life, so please include as much info as possible. Thank you!

Health History and Intake Form

* Indicates required field

Name *

First

Last

How did you initially hear about Essential Somatics and Kristin Jackson? If someone referred you please let us know! *

What are your goals you'd like to address in your Somatics session(s)? *

Please list any injuries, accidents, falls, etc you have in your lifetime and approximate year in which they occurred. (Please include side of the body when listing injuries, i.e. left knee surgery, broke right wrist in 1986, etc) *

Please list any surgeries you have had and year performed. *

What do you do for work? Manual labor, desk job, etc. If retired, please include what you did before retirement. *

What kinds of activities/hobbies do you enjoy? (golf, skiing, cycling, gardening, knitting, computer games, etc) *

Please check the modalities you have explored to address your issue. *

chiropractic massage therapy acupuncture physical therapy yoga/yoga therapy surgery pilates prescription pain medications OTC pain medications none of the above other

Of those modalities, which ones do you currently use? If there are other modalities/treatments, please list them. *

Submit

Let's make the world a better place with Somatics!

Welcome!
About
join the virtual classroom
- Student Only Access to the Virtual Classroom >
  - log out
Services
contact