Form #1

Administrative & General Info

Please fill out all fields to the best of your ability

Name*
First Last
D.O.B.*
MM slash DD slash YYYY
Sex*
- Male
- Female
Is there any possibility that you could be pregnant?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Phone Number
(###) ###-####
Email*
Enter Email Confirm Email
Occupation*
Marital Status*
- Married
- Single
- Divorced
- Widowed
Emergency Contact Name*
First Last
Emergency Contact Phone*
Sports / activities you participate in*
Spouse / Children / Family activities*
Who referred you to this office?
How often do you exercise?*
- Daily: (6-7x/wk)
- Frequently: (4-5x/wk)
- Intermittently: (2-3x/wk)
- Occasionally: (1-2x/wk)
- Never: (b/c of pain or no time)
- Never: (don't want to)
Have you ever smoked?*
- Yes
- No
Number of years*
Please enter a number from 0 to 100.
How much do you smoke? (Packs per day)*
- None
- Less than 1/2 pack
- 1/2 - 1 pack
- 1-2 packs
- 2 packs
How often do you drink alcohol?*
- Never / Rarely: (1x/mo)
- Occasionally: (1x/wk)
- Moderately: (2-3x/wk)
- Frequently: (4-5x/wk)
- Everyday: (6-7x/wk)
In what position do you sleep?*
- Back
- Stomach
- Side w/ knees together
- Side w/ top knee closer to chest
What is your typical stress level?*
(1=Mild and 10=Severe)
What are your daily strategies to lower your stress?*
Describe your job duties at work*
Does the chair you normally sit in have a headrest?*
- Yes
- No
How many hours per day do you sit?*
Please enter a number from 0 to 24.
Consent statement*
By entering my full name in the field below, I am signing the form
Client Signature*

If the client is not yet 18 years old, a parent or guardian must sign.
Today's Date*
MM slash DD slash YYYY
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Jennifer Corey

480.747.8902

9312 E. Raintree Drive

Scottsdale, AZ 85260

Jennifer@magnoliatherapeutics.net