Scar Release Therapy Intake Form
Please complete this intake form so we can understand your scar history, current symptoms, and therapy needs before your session.
Client Information
Full Name
*
First Name
Middle Name
Last Name
Preferred Name
Date of Birth
*
-
Month
-
Day
Year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Preferred Contact Method
*
Phone
Email
Text Message
Other
Emergency and Appointment Details
Emergency Contact Name
*
First Name
Middle Name
Last Name
Relationship to Emergency Contact
*
Please Select
Parent
Spouse/Partner
Sibling
Child
Friend
Other
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Appointment Date/Time
Scar History and Current Concern
Scar location(s)
*
Face
Neck
Chest
Back
Abdomen
Arm
Hand
Leg
Foot
Other
Approximate age of scar
*
Please Select
Less than 3 months
3–6 months
6–12 months
1–2 years
2–5 years
More than 5 years
Unknown
Cause or origin of scar
*
Please Select
Surgery
Burn
Accident/Injury
Cut/Laceration
Medical procedure
Skin condition
Unknown
Other
Number of scars being treated
*
Current symptoms or concerns
*
Pain
Tightness
Itching
Sensitivity
Mobility restriction
Raised/thickened tissue
Color change
Cosmetic concern
Other
Current severity
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Medical Background
Past surgeries or procedures related to the scar area
Current skin conditions or concerns
Any history of delayed healing, keloids, or hypertrophic scarring
Current medications or supplements
Allergies or sensitivities
Latex
Adhesives
Topical products
Medications
Fragrances
Other
Pregnant or breastfeeding
Pregnant
Breastfeeding
Neither
Not applicable
Previous Treatment and Goals
Have you tried any previous scar treatments or therapies?
*
Yes
No
Not sure
What helped or did not help?
Primary treatment goals
*
Reduce tightness
Improve appearance
Decrease pain or sensitivity
Increase mobility
Reduce itching
Improve comfort
Other
Functional limitations related to the scar
None
Pain with movement
Limited range of motion
Difficulty with exercise
Difficulty with work tasks
Difficulty with daily activities
Clothing irritation
Sleeping discomfort
Other
Questions, concerns, or additional notes
Submit
Should be Empty: