CTB Intake Form

Let's work together to get to the bottom of your pain!

If using a cell phone to complete intake, you may have to move from grey boxes using the up/down arrow next to the x to close out.

An (*) means its a required field. It will let you know if you missed something when you complete and press send. Just go back and answer and send again.

You can say none or n/a if a question doesn't apply to you.

Please just guestimate dates. If it's not within the past two years round to the nearest year.

Thanks so much for choosing Freedom! Heidi



Medical History:



Medications:



Pain History:



Jaw/Facial Pain:



Life/General:



Home Stress:



Work Stress:



Activities/Hobbies:



Excercise:



Sleep:



Alcohol/Tobacco/Caffeine/Sugar: (If no, write n/a)

Consent for Freedom's Coaching The Body Treatment: