Health Update & Treatment Plan Review

This form helps us keep your care safe, personalized, and aligned with your current needs. Please complete it before your appointment, even if you believe nothing has changed. Your responses will help us determine whether your existing treatment plan remains appropriate.

01. Client information

Full Name

Date of Birth

02. Changes in health since your last intake

Since completing your last intake or attending your last appointment, have you experienced any changes in your health, including new diagnoses, medications, injuries, surgeries, hospitalizations, pregnancy or postpartum status, allergies, or skin sensitiv

No, nothing has changed.

Yes, I have changes to report.

I'm unsure whether a change is relevant.

List any updates here.

03. Current symptoms and physical changes

Have your symptoms or physical condition changed since your last visit? This includes pain, mobility, swelling, numbness, tingling, weakness, or new areas of concern.

No significant changes.

My symptoms have improved.

My symptoms have worsened.

I have new symptoms or concerns.

Are you experiencing any new or unexplained symptoms that you have not yet reported to a healthcare provider?

No

Yes

I'm not sure

04. Treatment plan progress

How has your treatment been affecting your goals, such as pain relief, mobility, posture, daily function, recovery, or relaxation?

What would you most like us to focus on during your upcoming session?

05. Treatment preferences and consent

Have your preferences or comfort needs changed regarding pressure, techniques, areas to avoid, positioning, draping, or communication during treatment?

No, my preferences remain the same.

Yes, I would like to make changes.

06. Acknowledgement and consent

I confirm that the information I have provided is accurate and complete to the best of my knowledge. I agree to notify my practitioner of relevant health changes before treatment.

I understand that this update will inform my care but does not replace an assessment when one is clinically indicated. I understand that treatment will be discussed with me and that I may decline or withdraw consent for any technique at any time.

Signature

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