Trapezius Muscle Knot Relief Intake Form
Please complete this form to help us understand your symptoms and provide the best care for your trapezius muscle knot relief session.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date and Time
*
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
How long have you been experiencing trapezius muscle knots?
*
How would you rate your current pain or discomfort?
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Which of the following best describes your pain?
*
Dull ache
Sharp/stabbing
Burning sensation
Tingling/numbness
Other
Have you had any previous treatments for this issue?
*
Yes
No
If yes, please specify previous treatments (e.g., massage, physical therapy, medication):
Do you have any existing medical conditions or injuries we should be aware of?
Please list any medications or supplements you are currently taking.
What activities or factors seem to trigger your muscle knots?
Poor posture
Stress
Repetitive movement
Heavy lifting
Unknown
Other
What is your primary goal for today's session?
*
Signature (please sign below to confirm your consent)
*
Submit Intake Form
Submit Intake Form
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