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Realign Therapy

If you have disabilities that prevent you from filling out these applications send a quick email to RealignTherapyOntario@gmail.com and we can book a time to do it over the telephone.

Currently available at The Healing Nook, 7 Russell St. W, Smiths Falls, ON

🔹 Comprehensive Manual Therapy & Exercise Therapy 🔹

Your responses are confidential, encrypted in transit and at rest through a standard DPA, both GDPR and PIPEDA compliant. It is never shared with third parties. By executing this agreement, you acknowledge and assume all risks associated with your participation and agree to release, indemnify, and hold Micaela Hickman-Pearce, Realign & Associates harmless from and against any and all claims, liabilities, damages, losses, costs, and expenses, except where prohibited by law. Medical Disclaimer - Realign Therapy does not replace medical care. It is always safest to consult with your primary care provider before making lifestyle changes or beginning exercise.

Initial Health Intake Form

Please answer as in depth as possible, and please feel comfortable sharing anything you'd like to. You'd be surprised by what's relevant - the more I know up front the better.

Email

Name: First & Last

Date of Birth

Anatomical Sex (at birth, for clinical assessment)

Please tell us about any and all significant situations your body has been through - including surgeries, serious injuries, births, recurring areas of injury, car accidents, broken bones, concussions – list anything you can think of - even childhood injuries, or smaller injuries that didn’t heal “quite right”.

Tell us about any other health concerns or diagnoses you may have – please list anything from diabetes, hypermobility, tinnitus, heart conditions, medications, to allergies, etc.

Are you in active pain or discomfort in your body, and if so, where? Please include all types of discomfort, such as sciatica, back aches, feeling restricted, joint aches, neuropathic pain, or anything you can think of.

Are there any types of movements that are uncomfortable for you? Such as jumping, putting weight on your wrists or knees, running, or getting up and down off the ground – please list any information that comes to mind.

Please list any and all other symptoms/conditions you experience, even if they may seem unrelated – bladder incontinence, IBS, erectile dysfunction, pain with sex, digestive issues, chronic pain conditions, nervous-system or cognitive conditions, and please include anything you’re comfortable sharing related to your mental and emotional health.

The body’s needs can change drastically depending on what our life looks like – so please tell me about your lifestyle! Share anything you’re comfortable with. How do you like to spend your time? If you’re working, what do you do? Hobbies? And anything you’re comfortable sharing about your support system. (This information can help us better form relevant treatment plans/lifestyle ergonomics plans, and help us understand your body’s needs.)

How much stress are you under or feeling on a regular basis - and where would you say it stems from? Mention whatever you feel comfortable sharing.

Please take a moment to share any other thoughts, concerns or anything else you'd like to mention before we meet:

Thank you for taking the time to fill this out.

Looking forward to getting started with you!

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I certify the above information as correct and true, and I consent to the above clauses and the collection and secure use of my information as described above.

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