Intake Questionnairre «

Please send this form to:*

Margy Verba
Jessi DeLong
Both

Name*

First Last

Email*

Phone

1. Your Age:

2. Please list injury/pain /surgery history in chronological order.

(approximate dates are fine) NOTE: More is better in this case. Even if you think a previous injury is not pertinent to your current complaint, please include. For example: every ankle sprain, falling off your bike as a child, concussions, etc.

3. Primary complaints (describe your pain) and movements or positions that trigger your pain.

(please be as specific as possible)

4. Scar locations (c-sections and episiotomies count)

5. Do you have postural cues for yourself, and if so what are they?

— e.g. “stand up tall”, “lift the heart”, “shoulders back and down”, etc.?

Divide your feet into inside / outside / front / back.

6. You will end up with four quadrants on each foot: inside-front, inside-back, outside-front, & outside-back. Stand up and take a moment to determine where you feel you are weight bearing on your feet. It may help to close your eyes. Where do you weight bear?

7. Do you have any issues with elimination — e.g. incontinence, constipation, urgency, frequency, etc.?

8. What does a typical week looks like in terms of physical activity (e.g. walk a lot, sits at a desk, etc.)?

9. What type of exercise do you do if any?

10. Pertinent medical findings — if you have had imaging or a previous diagnosis, please share along with the name of the practitioner.

11. What have you tried to get better (e.g. chiropractic, etc.)? How did it go?

Practitioners working with me and your client, please also the following assessments:

1. Static postural assessments of pelvis, ribs, and skull in all planes.

(if you know how to assess for intra-pelvic torsion, please do so)

2. Facing of talii.

3. Forefoot varus.

4. Any other assessment notes:

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FlowMotion Back and Joint Therapy

Healing Through Movement

Intake Questionnairre

Please answer the following questions.

Divide your feet into inside / outside / front / back.

Practitioners working with me and your client, please also the following assessments: