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 pronouns do you use?
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. *
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:
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
Cardiovascular Conditions
Metabolic & Hormonal Conditions
Are you pregnant or trying to get pregnant?
Other health history that might be pertinent
Is there anything else you would like me to know?