First Name(Required)
Last name(Required)
Email(Required)
Phone(Required)
Emergency Contact(Required)
Emergency Contact Phone(Required)
Who are your primary and secondary medical providers? (PCP, OBGYN, psychiatrist, chiropractor, etc). Please include full name, address, and reason for seeing. This is optional for now, but practitioner may request specific information later to interface with other professionals regarding care/treatment. As well, radiological information or blood panel may be helpful.
1. Name, office address, business phone, and care provided
2. Name, office address, business phone, and care provided
3. Name, office address, business phone, and care provided
4. Name, office address, business phone, and care provided
5. Name, office address, business phone, and care provided
Please list any medications you are currently taking.
1. Name of medication, dosage, reason for taking, and for how long?
2. Name of medication, dosage, reason for taking, and for how long?
3. Name of medication, dosage, reason for taking, and for how long?
4. Name of medication, dosage, reason for taking, and for how long?
5. Name of medication, dosage, reason for taking, and for how long?
6. Name of medication, dosage, reason for taking, and for how long?
7. Name of medication, dosage, reason for taking, and for how long?
8. Name of medication, dosage, reason for taking, and for how long?
Please list any meds you have taken in the past for more than six months but no longer take and why you started and stopped.
1. Name of medication & why you stopped taking it.
2. Name of medication & why you stopped taking it.
3. Name of medication & why you stopped taking it.
4. Name of medication & why you stopped taking it.
5. Name of medication & why you stopped taking it.
Do you take any nutritional/dietary supplements? If so, please list below.
1. Name of supplement, dosage, reason for taking, and for how long?
2. Name of supplement, dosage, reason for taking, and for how long?
3. Name of supplement, dosage, reason for taking, and for how long?
4. Name of supplement, dosage, reason for taking, and for how long?
5. Name of supplement, dosage, reason for taking, and for how long?
Do you presently have, or in the past suffered, from any of the following issues:
Has your doctor diagnosed, or do you have a history of heart problems, chest pain, or stroke?(Required)
Has an immediate family member (parent/sibling) had a heart attack, stroke, or cardiovascular disease before the age of 55 yrs old?
Do you frequently have pains in your heart and/or chest when you do physical activity?(Required)
Do you lose balance because of dizziness or do you ever lose consciousness?(Required)
Is(are) your doctor(s) currently prescribing drugs for blood pressure or heart condition?
Are you over the age of 65 and NOT accustomed to vigorous exercise?
Do you have high cholesterol or HDL:LDL imbalance?
If you answered YES to smoking, please select which type of smoking:
If you smoke, how much and for how long?
Are you medically considered obese? (BMI of 30+)
Do you have asthma or trouble breathing?(Required)
Have you ever had a stroke or heart attack?
Are you a male older than 45?
Are you a female older than 55?
If you are female, are you currently pregnant or have been within the last 12 months?
If you are female, how many children have you had?
Do you have any learning disabilities or cognitive challenges?(Required)
Do you consume any alcoholic beverages? (beer, wine, liquor, etc)(Required)
How much alcohol do you consume weekly in oz?
Do you have difficulty swallowing food or chewing food?
Is there any reason not to mentioned thus far to preclude you from regular exercise activity?
Do you have urinary incontinence?
Please elaborate here if you checked "yes" for any required fields.
List any non-prescription drugs (marijuana, cocaine, etc.)
Please complete the following information as thoroughly as possible. This is an extremely important section.
Trauma/injury/surgery history (Every significant physical pain you have experienced) includes even what you might consider minor, non-medically treated injuries.
Head/Jaw injuries and at what age were the injuries sustained?
Cervical/Neck injuries and at what age were the injuries sustained?
Thoracic/Mid-back injuries and at what age were the injuries sustained?
Lumbar/Low-back injuries and at what age were the injuries sustained?
Abdominal/Rib injuries and at what age were the injuries sustained?
Pelvis/Hip/Femur/Thigh injuries and at what age were the injuries sustained?
Shoulder/Scapular/Rotator Cuff injuries and at what age were the injuries sustained?
Elbow injuries and at what age were the injuries sustained?
Wrist/Hand/Finger injuries and at what age were the injuries sustained?
Knee/Patellar/ACL injuries and at what age were the injuries sustained?
Ankle/Foot injuries and at what age were the injuries sustained?
Do you wear orthotics? And how long have you worn them?
Have you had any cosmetic/plastic surgery? Please describe below.
Diagnosed diseases. Please provide all medical reports (x-rays/MRI/CT Scan)
Describe any physical and emotional stressors you may experience while performing your duties. Please include frequency, magnitude, and duration.
List current physical pain/discomfort and rank the severity from 1 to 10, with #1 being the worst pain/greatest concern.
Please select the corresponding checkbox if you are experiencing unusual levels of stress in the following areas:
Please describe a typical day of activity for you.
Please describe your shoe wear. What do you wear the most throughout the week?
Please describe your quality of sleep.
What are your daily work duties/demands?
What physical activities and/or physical positions cause discomfort or significant tension?
What self-care strategies do you currently use to manage your own health and why?
Do you play a musical instrument? If so, which instrument, how long, how many hours of practice/week?
What have you found to be positions of relief or things you do to manipulate you own body during the day to deal with any pain or discomfort?
Do you have confusion or frustration regarding exercise and wellness strategies? Or have had conflicting advice or information about exercise? If so, explain.
Do you feel that with each passing year you are getting healthier or unhealthier? Explain.
Please include any additional comments or concerns you may have.
