New Client Intake

Pain Relief Pittsburgh · Dan Gehret, LMT

Fill in as much or as little as you like. Skip anything you are unsure about or would rather talk through in person, we will fill the gaps together. There are no wrong answers, and you do not have to finish it in one sitting.

Your answers stay private. Nothing you type here is saved, sent, or seen by anyone while you fill this out. It stays on your own phone or computer, in this window. There is no account, no login, and nothing is stored on a website. At the end you will see everything you wrote, and you decide what to send and email it to Dan yourself.

Your first and last name *

Step 1

What is bringing you in?

List what is bothering you, one line each, most important first. Do not over-work it, we can go deeper together in a moment.

Step 2

Your health history

Please list everything, even things you assume I do not treat or that seem unrelated. Organs, circulation, nerves, and old injuries all connect to the fascia I work with, so more is better.

Diagnoses and ongoing conditions Surgeries, injuries, accidents, hospitalizations, physical traumas (with the year if you remember, a rough year is fine)

Step 3

Medications and supplements

Names only, doses do not matter, and do not work too hard on this. What you take tells me a lot about what your body has been dealing with, so more is better.

Allergies or sensitivities (just the types, e.g. food, essential oils)

Step 4

Quick body check

This list is here to jog your memory. Tick anything that is true for you now or in the past, even if it seems unrelated to why you came in. You may have already mentioned some of it above, no need to be careful about repeating yourself, I will connect the dots.

Something not listed

Step 5

About your days (optional)

What does your body do most days? Your work and main activities, roughly how often.

Step 6

Comfort on the table (optional)

Many people carry physical or emotional history that affects how they receive bodywork. If there is anything you would like me to avoid, or that helps you feel comfortable and in control on the table, tell me as much or as little as you like, or we can just talk about it in person.

Step 7

Your goal (optional)

No need to repeat what you already listed above — easing those is a given. Beyond that, is there something specific you would like to get back to? For example being able to dance, sleep through the night, garden, pick up your kids, or sit through a workday.