Health History Intake Form
This form is for new 1-on-1 clients. The more information that I have about your past or current injuries, issues, and goals the more effectively I will be able to help you. Please take time filling this out and be as thorough as you can be.
What are your main goals in working together?*
Have you had any surgeries?
What, if any, musculo-skeletal issues have you had?
Do you have any current pain or movement issues with your
Feet/Knee/Hip
Wrist/Elbow/Shoulder
Spine/Neck/Head
Please list your current physical activities, frequency (how many times per week), and duration (how long have you been doing this?)*
Musculoskeletal Conditions/History
Osteoarthritis
Chronic Joint Pain
Sprains/Broken Bones
Spinal Conditions
Scoliosis
Osteoporosis or Osteopenia
Bulging or Herniated Disks
Sciatica
Degenerative Disc Disease
Other
Cardiovascular Conditions
High or Low Blood Pressure
Asthma or shortness of breath
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
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 neurological conditions
Other health history that might be pertinent
Autoimmune disease
Memory loss or confusion
Depression and/or anxiety
Endocrine or thyroid conditions
Diabetes
Digestive: gas/bloating/constipation
Kidney disease or infection
Are you pregnant or trying to get pregnant?
yes
no
Is there anything else you would like me to know?