Touchpoint To Function — Patient Health History

Personal Information

Not started

First Name * Max 50 characters

Last Name * Max 50 characters

Date of Birth *

Hand Dominance

Phone Number * Max 20 characters

Email Address Max 100 characters

Street Address Max 100 characters

City Max 60 characters

State

ZIP Code Max 10 characters

Occupation Type

Job Title / Role Max 80 characters

How did you hear about us?

Referred by (name, if applicable) Max 100 characters

Emergency Contact

Not started

Contact Name * Max 100 characters

Relationship to Patient Max 50 characters

Contact Phone * Max 20 characters

Primary Care Physician Max 100 characters

Reason for Your Visit

Not started

Primary concern or reason for seeking therapy * Max 500 characters

When did this problem begin? (approximate date or timeframe) Max 100 characters

How did it start? (gradual, sudden, injury, illness, surgery, etc.) Max 300 characters

Pain / Discomfort Location (check all that apply)

Current Pain Level 0 = none | 10 = worst imaginable

No painWorst imaginable

Worst Pain Level in the Past Month

No painWorst imaginable

Pain / symptom pattern

Constant Intermittent (comes and goes) Worse with activity Worse at rest Worse in the morning Worse at night

What makes it better or worse? Max 400 characters

Previous treatments received for this condition Max 400 characters

What are your goals for therapy? * Max 500 characters

Medical History

Not reviewed

Please check any conditions you currently have or have had in the past:

Other medical conditions not listed above Max 500 characters

Recent injuries, accidents, or hospitalizations (within the past 2 years) Max 400 characters

Have you experienced a concussion or head injury?

Yes No Unsure

If yes, please describe (date, circumstances, symptoms) Max 400 characters

For female patients — are you currently pregnant?

Yes No Not applicable

If pregnant, how many weeks along? Max 20 characters

Surgical History

Not reviewed

List any surgeries or significant procedures. Scar tissue from surgery may influence treatment approach.

Year (approx.)	Procedure / Surgery	Body Area	Complications or Lasting Effects

Medications & Supplements

Not reviewed

Include prescription medications, over-the-counter medications, vitamins, herbal supplements, and injections (e.g., cortisone, Botox).

Medication / Supplement	Dosage	Frequency	Reason / Condition

Do you have known medication allergies?

Yes No

If yes, list medications and reactions Max 300 characters

Functional Limitations & Daily Activities

Not reviewed

Which daily activities are currently difficult or limited? (check all that apply)

Describe any specific limitations not listed above Max 400 characters

Physical activity level (before this current problem)

Sedentary Light (walking, light housework) Moderate (regular exercise) Active (sports, vigorous exercise) Highly active (athlete, physical labor)

Sleep quality

Generally good Disrupted by pain or discomfort Poor (difficulty falling or staying asleep)

Current stress level and relevant stressors Max 400 characters — optional

Infant / Pediatric Information (if applicable)

Not reviewed

Complete only if the patient is an infant or child, or if you are completing this form on behalf of one.

Additional Information

Not reviewed

Is there anything else you would like Anne to know before your visit? Max 800 characters

Have you received Craniosacral Therapy (CST) or Myofascial Release (MFR) before?

Yes — Craniosacral Therapy Yes — Myofascial Release Yes — Both No, first time

If yes, describe your experience and what helped or did not help Max 400 characters

Privacy Notice & Consent

Not started

Notice of Privacy Practices — Touchpoint To Function, LLC

Your health information is protected under the Health Insurance Portability and Accountability Act (HIPAA). Touchpoint To Function, LLC collects health information solely for the purpose of providing occupational therapy and soft tissue treatment services. This information will not be shared with third parties without your written consent, except as required by law.

By signing below, you acknowledge that you have been informed of this practice’s privacy practices, you consent to the collection and use of your health information for treatment purposes, and you understand that you may request a copy of the full Notice of Privacy Practices at any time.

You also consent to receive communications regarding your care via the phone number or contact method you have provided above.

I have read and acknowledge the above Privacy Notice and consent to treatment. *

* Required fields

By submitting this form, you agree to our Terms of Use and Privacy Policy.

Thank You!

Your health history has been submitted. Anne will review your information prior to your appointment.
Questions? Call or text 414-840-8494.

Back to Home