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New Client Intake

Welcome — I can’t wait to get you started on your healing journey. Prefer to talk first? Ask for a free 15-minute phone consultationand Carolyn will call you back, or text / call (808) 289‑0601. Ready to book a time? Visit Schedule Now.

Which best describes your visit?

Choose the option that fits best and a short intake form will open. Not sure which to pick, or prefer to talk first? Call or text (808) 289‑0601 and we’ll help. All information is confidential.

Orthopedic concernPain or injury — back, neck, joints, muscles, post-surgical, etc.

For a new orthopedic concern (pain, injury, or post-surgical care). Share as much as you can — it helps Carolyn prepare for your first visit. All information is confidential.

Your information

Name (required)

Email (required)

Phone

Address

About your concern

Why are you seeking Physical Therapy? (required)

Which activities or "inactivities" bring about your pain, and how long do they last?

Example: It bothers me most when I'm getting out of bed in the morning; it lasts about 20 minutes and then I'm good until the next morning.

Which activities or positions relieve your pain?

Do your symptoms fluctuate by the time of day, or more by what activities you are performing?

Example: My symptoms are worse at the end of the day.

Is your pain constant throughout the day? If so, rate its intensity.

1 = no pain, 10 = call 911. Example: My pain is a 4 in the morning and a 7 by evening.

How long ago did your symptoms begin? Was there a specific injury? Please describe.

Have you experienced any numbness, tingling, headaches, dizziness, or changes in bowel or bladder function?

Do you have other areas of injury or pain besides the one you are seeking treatment for?

What activities are you unable to perform that you would like to be able to do?

Have you had any falls in the last year?

Medical history

Please list any medications you take for pain, and how often.

Example: I take 600mg ibuprofen twice daily.

Please list any other medications you take for any other condition.

Have you had any MRI, x-ray, or other diagnostic testing? When, and what were the results if you know?

Have you had a recent physical examination from your doctor?

Have you had any previous Physical Therapy for this condition? If so, when and where, and did it help?

Lifestyle & goals

What are your job, sport, or activity requirements or goals?

Example: I need to spend at least 2 hours a day gardening.

Do you exercise regularly? If so, what do you do?

Example: I walk for 45 minutes every day but currently can’t because of the pain.

What is your sleep quality and quantity? How do you feel when you wake up?

Please include any other details you want the Physical Therapist to review prior to your visit.

Finishing up

Preferred method of contact

Phone callTextEmail

How did you hear about us?

Chronic conditionOngoing conditions — sleep, balance, GI, autoimmune, fatigue, dysautonomia, and more.

For ongoing or complex conditions. This questionnaire is detailed by design — answer what is relevant and skip anything that is not. All information is confidential.

Your information

Name (required)

Email (required)

Phone

Address

What brings you here

Please describe in your own words what brings you here today. (required)

How long have you been experiencing these symptoms?

Have you been formally diagnosed with a condition?

YesNoSuspected but not confirmed

If yes, please list all diagnoses and who made each diagnosis.

If we may communicate with your provider, please provide their phone number.

Fatigue & energy

Rate your fatigue over the last week (1–10, 10 = completely exhausted).

Do you experience post-exertional malaise (symptoms significantly worsening after physical or mental effort)?

YesNoSometimes

Does rest relieve your fatigue?

Yes, reliablySomewhatRarelyNo

Psychological & social wellbeing

Skip any lines that aren’t relevant for you.

Psychological & social wellbeing

Over the past two weeks, felt anxious, worried, or on edgeOver the past two weeks, felt down, hopeless, or had little interest in activitiesA history of trauma or ACEs (Adverse Childhood Experiences) that may be affecting your healthFeel your symptoms are connected to your stress levelsHave a mindfulness, meditation, or nervous-system regulation practice

If you have a regulation practice, describe it and how often.

Current stress level (1–10, 10 = worst)

Function & quality of life

Skip any lines that aren’t relevant for you.

In the past week, have your symptoms impacted any of the following?

Overall level of impact (1–5, 5 = severe)

List the top 2–3 things you most want to be able to do that your condition is currently limiting.

Movement, posture & physical activity

Skip any lines that aren’t relevant for you.

Movement & posture

I currently exercise or do physical activityPhysical activity worsens my symptomsI have noticed posture changes since my condition beganI experience stiffness in the morningMy breathing is shallow, or I frequently hold my breathI clench my jaw, grind my teeth, or carry significant tension in my face/neck

Detail the type, frequency, and duration of your exercise.

Goals & prior care

What are your top goals for working together?

What does success look like to you 3 months from now?

Have you worked with a Physical Therapist or Wellness Specialist before?

YesNo

If yes, was it helpful?

YesNot particularly

What could have been better?

Is there anything else you would like me to know before we begin?

Finishing up

Preferred method of contact

Phone callTextEmail

How did you hear about us?

Personal training & wellnessFitness coaching, strength, conditioning, and general wellness.

For personal training and wellness clients. Please answer all sections as thoroughly and honestly as possible. All information is confidential.

Your information

Full Name (required)

Date of Birth

Age

Gender

Pronouns

Email (required)

Phone

Address

Occupation

Work Schedule

Work Hours / Week

Referred by

Emergency contact

Emergency Contact Name (required)

Emergency Contact Relationship (required)

Emergency Contact Phone (required)

Physical activity readiness (PAR-Q)

If you mark any of these, please consult your physician before starting a training program.

Physical activity readiness

Has your doctor ever said you have a heart condition and that you should only do physical activity recommended by a doctor?Do you feel pain in your chest when you do physical activity?In the past month, have you had chest pain when you were not doing physical activity?Do you lose your balance because of dizziness, or do you ever lose consciousness?Do you have a bone or joint problem that could be made worse by a change in your physical activity?Is your doctor currently prescribing drugs for your blood pressure or heart condition?Do you know of any other reason why you should not do physical activity?

Fitness history & experience

Rate your experience level from 1 (none) to 5 (advanced).

How many days per week do you exercise (light, moderate, or vigorous)?

Free Weights experience (1–5)

Machines experience (1–5)

Bodyweight Training experience (1–5)

Cardiovascular Training experience (1–5)

Flexibility / Mobility experience (1–5)

Group Fitness experience (1–5)

Sport-Specific Training experience (1–5)

Olympic Lifts experience (1–5)

Describe your current exercise routine (if any).

What types of exercise do you enjoy?

What types of exercise do you dislike or want to avoid?

Have you worked with a personal trainer before? If so, describe what worked and what didn’t.

Nutrition

Meals per day

Snacks per day

Do you follow any specific diet? Specify details.

Water intake / day

Caffeine intake / day

Alcohol drinks / week

Tobacco use

Describe a typical day of eating.

Any food intolerances or restrictions?

Would you like nutritional guidance as part of your program?

Sleep & stress

Average hours of sleep

Typical bedtime

Rate your sleep quality (1 = worst, 10 = best)

Do you have trouble falling or staying asleep?

Rate your daily stress level (1 = lowest, 10 = highest)

Primary sources of stress

Logistics & preferences

Training sessions / week desired

Training session length

Preferred training session days / times

Preferred training location

Therapeutic Connection’s gym, in-home, outdoors, or virtual.

Do you have access to any equipment at home?

Communication preference between sessions

Text, email, or phone call.

Coaching style preferences

Firm and direct, encouraging and supportive, or educational.

Is there anything else you’d like your trainer to know about how you learn and work best?

Finishing up

Preferred method of contact

Phone callTextEmail

How did you hear about us?