Name
*
First Name
Last Name
Email
*
Phone
*
(###)
###
####
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Your date of birth
*
MM
DD
YYYY
Emergency contact
*
First Name
Last Name
Emergency contact's phone number
*
(###)
###
####
Emergency contact's relationship to you
*
Estimated due date
*
Insert today's date if you are not currently pregnant.
MM
DD
YYYY
Has your doctor ever said that you have a heart condition and recommended only medically supervised physical activity?
*
Do you frequently have pains in your chest when you perform physical activity?
*
Have you had chest pain when you were not doing physical activity?
*
Do you lose your balance due to dizziness or do you ever lose consciousness?
*
Do you have a bone, joint or any other health problem that causes you pain or limitations that must be addressed when developing an exercise program (i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis, anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)?
*
Are you pregnancy now or have given birth within the last 6 months?
*
Have you had a recent surgery?
*
Please explain any YES answers from the section above or write "N/A" if you didn't have any.
*
Right shoulder
Please check all conditions you have encountered throughout your lifetime.
Left shoulder
Please check all conditions you have encountered throughout your lifetime.
Head/neck
Please check all conditions you have encountered throughout your lifetime.
Neurological/limbic
Please check all conditions you have encountered throughout your lifetime.
Spine/upper back
Please check all conditions you have encountered throughout your lifetime.
Lymphatic
Please check all conditions you have encountered throughout your lifetime.
Cardiovascular
Please check all conditions you have encountered throughout your lifetime.
Respiratory
Please check all conditions you have encountered throughout your lifetime.
Digestive
Please check all conditions you have encountered throughout your lifetime.
Organ Functions
Please check all conditions you have encountered throughout your lifetime.
Right arm/hand
Please check all conditions you have encountered throughout your lifetime.
Left arm/hand
Please check all conditions you have encountered throughout your lifetime.
Right leg/knee
Please check all conditions you have encountered throughout your lifetime.
Left leg/knee
Please check all conditions you have encountered throughout your lifetime.
Reproductive/Urologica
Please check all conditions you have encountered throughout your lifetime.
Spine-lower
Please check all conditions you have encountered throughout your lifetime.
Right foot/ankle
Please check all conditions you have encountered throughout your lifetime.
Left foot/ankle
Please check all conditions you have encountered throughout your lifetime.
Please further describe any boxes you checked above that you feel need further explanation, or write "N/A" if none of the above boxes were checked.
*
Please list and briefly describe any previous injuries and hospitalizations, or write "N/A".
*
Please list any sports or physical activities that you have participated in regularly in the past and in what capacity you participated.
*
What are your goals for our session(s)?
*
Please describe what led you to set up your appointment with me.
*
How did you learn about my services?
*
