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Adult Intake Form
Adult Intake
First Name:
Last Name:
Birthday
Address:
Phone:
Email:
Emergency Contact: Name and Phone Number
Please list your goals for the FMCM or Matrix in Motion Somatic Movement Therapy Program .
Please list any traumas that have occurred to you in your lifetime (falls, injuries, accidents, emotional trauma, and any other life stresses that you would like to share). Include the approximate date of injury or event.
Are you under the care of a primary healthcare provider or specialist?
Yes
No
Name of healthcare provider and/or facility.
Please list medications or supplements you are currently taking.
Please list any special dietary/nutritional considerations. (Ex. Gluten-free, allergies, etc.)
Please mark any of the following conditions that you have currently or have had in the past. Identify the condition and location where applicable. Muscle conditions (include strains, tendonitis, spasms, etc.)
Joint conditions (includes arthritis, degenerating joints, etc.)
Nervous system conditions (including numbness, tingling, nerve damage, shingles, etc.)
Respiratory conditions (includes sinus, lung, and bronchial conditions, etc.)
Infectious or communicable conditions
Circulatory conditions (includes heart, blood pressure, arterial/venous conditions)
Reproductive conditions (includes prostate, menstruation issues, etc.)
Digestive conditions (includes constipation, diarrhea, IBS, etc.)
Have you been diagnosed, or experience symptoms related to anxiety, depression, PTSD, etc.? If yes, please explain
Dental History: Do you have implants?
Yes
No
Have you had teeth extracted? If so, how many?
Do you have any crowns, bridges, or dentures? If yes, please specify.
Have you worn orthodontics in the past or do you currently wear orthodontic appliances?
Yes
No
Therapeutic History: Are you receiving massage, bodywork, or manual therapies? (Ex. Chiropractic, Craniosacral, Acupuncture, etc.) If yes, please list therapies:
Authorization and Disclaimer Information I understand that I will be participating in Matrix Energy Healing/FMCM as a form of adjunct healthcare. I have noted in my intake all complications, risks, or conditions that I experience, and I have obtained my healthcare provider’s release if necessary. I understand that I will receive Matrix Energy Healing as a form of adjunctive health care only, and that it is not a substitute for other health care provided by a medical doctor. I hear by release and hold harmless and defend the Myers Institute®/FMCM Specialist from any claims, liability, demands, and causes of action from my participation in therapy.
Name
Date
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Myers Institute
®
West Palm Beach, Florida 33401
484.336.3243
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®
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