Occipital Muscle Release Intake Form
Please complete this intake form so we can understand your symptoms, relevant health history, and goals before your occipital muscle release session.
Client Information
Full Name
*
First 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
Session Details
Reason for Session
*
Please Select
Pain relief
Reduce neck tension
Headache relief
Improve posture
Increase mobility
Postural strain follow-up
Other
Main Symptoms or Discomfort
*
Pain Location
*
Occipital area / base of skull
Upper neck
Back of neck
One side of neck
Both sides of neck
Shoulders
Headache areas
Other
Pain Intensity
*
1
2
3
4
5
When Symptoms Began
-
Month
-
Day
Year
Date
Issue Pattern
*
New
Recurring
Ongoing
Medical History and Contraindications
Have you had any prior neck or head injuries?
*
No
Yes
Not sure
If yes, please briefly describe the injury and when it occurred
Have you had any recent surgery in the head, neck, or upper back area?
*
No
Yes
If yes, please describe the surgery and the approximate date
Have you been diagnosed with any of the following?
Headaches
Migraines
Cervical spine issues
Disc issues
TMJ/jaw issues
Vertigo or dizziness
None of the above
Other
Do you currently experience any of the following symptoms?
Dizziness
Numbness
Tingling
Radiating pain
Reduced range of motion
Muscle weakness
None of the above
Other
Are you currently taking any medications or supplements that may affect treatment?
Blood thinners
Anti-inflammatory medication
Muscle relaxants
Pain medication
Prescription headache medication
Supplements
None
Other
Please list any other conditions, injuries, or concerns the practitioner should know before treatment
Treatment Preferences and Goals
Session goals
*
Headache relief
Neck mobility
Muscle tension reduction
Stress relief
Posture support
Other
Preferred pressure level
*
Light
Moderate
Firm
Start light and adjust as needed
Areas to avoid
Back of head
Neck
Shoulders
Upper back
Scalp
Jaw
Other
Comfort and communication preference
Please check in often
Check in only if needed
Minimal talking
Explain what you are doing before each step
Other
Additional goals or treatment preferences
Health Acknowledgment and Consent
Client Signature
*
Submit
Submit
Should be Empty: