Clinical Somatic Intake Form

First Name *

Last Name *

Email Address *

I agree to receive emails from Dena McComb

These questions help guide safe, body-aware movement and education. You do not need to share any traumatic personal history to participate in your health.

What would you like your body to feel more capable of or comfortable with right now? *

Have you explored other approaches for pain, stress, or tension (medical, physical therapy, body-based practices, etc.)? *

What helps your body feel even slightly more at ease or settled? *

Are there any past injuries, surgeries, or physical events that still affect how your body moves or feels today? *

Do you experience any of the following? (Many people notice physical symptoms shift with stress, posture, or nervous system load. Please check any that apply to you currently.))Headache or MigrainesBack PainJaw Pain or ClickingVision IssuesNIghtmaresDigestive IssuesGrind TeethUnexplained Aches and Pains

If you said YES, to any of the above, please explain in space below:

How does your pain or tension tend to show up in daily life? (Examples: worsens with stress, improves with movement, fluctuates, feels unpredictable, etc.) *

Would you say your nervous system has been under increased demand or stress recently? *YesNoUnsure

If you said YES, what are you doing to manage it?

On a scale of 1 to 10, how would you rate your current level of stress? (1 being low stress and 10 being the highest) *

Are there any current responsibilities or demands that affect your energy or recovery?

Is there anything relevant to your movement, comfort, or participation that would be helpful for me to know?

I agree that this information is true, accurate and complete to the best of my knowledge.

Type your Full Name (First and Last) *

Date *

Clinical Somatic Assessment