Health History Intake Form

What pronouns do you use?

she/her

they/them

he/his

How did you hear about us?* required

Instagram

Facebook

Google

Friend

Professional Referral

Newsletter

Other

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. * required

Small Group Classes

Private Instruction

Semi Private Instruction

Goodbye Back Pain

Not Sure Yet

Do you have any current pain or movement issues with your:

Feet/Knee/Hip

Wrist/Elbow/Shoulder

Spine/Neck/Head

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

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