Health History Intake Form
Thank you for filling out this health history questionnaire. The more information that I have about your history, challenges, and current goals the more effectively I will be able to help you. 🌟
What would you like us to call you? (Preferred name)
What pronouns do you use?
she/her
they/them
he/his
What are your goals for working together? Where would you like to be 3 months from now? 6-12 months from now? *
Are you interested in specific services such as small group classes or private instruction? Please select all that apply, and it's okay if this changes or if you're not sure yet. *
Small Group Classes
Private Instruction
Semi Private Instruction
Goodbye Back Pain
Not Sure Yet
Please list your current physical activities, frequency (how many times per week), and duration (how long have you been doing this?)*
Do you have any current pain or movement issues with your:
Feet/Knee/Hip
Wrist/Elbow/Shoulder
Spine/Neck/Head
Please describe your movement limitations or pain patterns. When do you notice it, is there a time of day when it's worse? How long has this been an issue? Anything else you'd like to share?*
Musculoskeletal Conditions
Arthritis
Chronic Joint Pain
Sprains/Broken Bones
Scoliosis
Degenerative Disk Disease
Bulging or herniated disks
Osteoporosis or Ostepenia
Other
Cardiovascular Conditions
High or Low Blood Pressure
History of stroke or heart attack
Congestive heart failure
I have felt pain in my chest when I exercise
I have had chest pain when not performing any physical activity
I have lost my balance due to dizziness or have lost consciousness
My doctor has currently prescribed medication for blood pressure or for a heart condition
Other
Pulminary Conditions
Asthma or shortness of breath
Lung Infection
Long Covid
Other
Metabolic & Hormonal Conditions
Diabetes or Prediabetic
Menopausal
Other endocrine or thyroid issues
Other
Lymphatic/Circulatory
Current or chronic swelling
Bruise easily
Blood clots
Other
Neurological
Numbness or tingling
Headaches or Migraines
Chronic Pain
Epilepsy or Seizures
Dizziness or Ringing in the Ears
Other
Have you had any surgeries?
Are you pregnant or trying to get pregnant?
yes
no
Other health history that might be pertinent
Autoimmune disease
Memory loss or confusion
Depression and/or anxiety
Digestive: gas/bloating/constipation
Kidney disease or infection
Other
Is there anything else you would like me to know?