CLIENT INFORMATION



|CLIENT INFORMATION | DATE: |

|Full Name | |

|Date of Birth m/d/y Age | |

| | |

|Address | |

|City / Postal Code | |

|Home Phone | |

|Cell Phone | |

|Email address | |

EXISTING MEDICAL CONDITIONS: please check appropriate conditions.

__Diabetes __Asthma __Heart Condition __ Thyroid Problems

__Hernia __ Ulcer __ Hearing Loss __ Pregnancy

__ Arthritis __ Obesity __ Cholesterol __ Anemia

__Epilepsy __High/Low Blood Pressure __

__Other (please specify)

FAMILY HEALTH HISTORY:

List any major illnesses your family suffers from:

___________________________________________________________________

MEDICATIONS

Are you currently taking medications? YES NO

If you circles YES, please list the medication, and for what condition

Medication_______________________Condition____________________________

Medication_______________________Condition____________________________

Medication_______________________Condition____________________________

INJURIES

Do you have pain or have you injured any of the following areas:

__ Neck __ Upper Back __ Lower Back

__ Shoulder R / L __ Elbow R / L __ Wrist R / L

__ Hip R / L __ Knee R / L __ Ankle R / L

HEALTH CARE PROFESSIONALS

Do you have regular treatment from any of the following individuals?

___General Practitioner (annual) ___Massage Therapist

___Acupuncturist ___Chiropractor

___Physiotherapist ___Naturopath

CURRENT ACTIVITY LEVELS

1. Do you consider yourself to be active? YES NO

2. How often do you exercise? 0 1 2 3 4 5 6 7 days a week.

3. What exercise(s) do you enjoy?

__ walking __ jogging __ running

__ swimming __ tennis __ racquet sports

__ cycling __ indoor cycling __ stairmaster/elliptical

__ yoga/pilates __ group exercise __ weight training

__ other____________________________________________________________

Is there any reason why you are unable to exercise regularly?

___________________________________________________________________

LIFESTYLE

1. Rate your stress on a daily basis: Low Moderate High

2. How much sleep do you average each night? 5 6 7 8 9 10 hours.

3. Do you smoke? YES amount NO

4. Alcohol Consumption? None Mild Moderate Frequent

NUTRITIONAL HABITS

1. Weight NOW______________lbs. Ideal Weight______________lbs.

2. Do you follow a special diet? YES NO

3. How would you rate your eating habits? Poor OK Good Very Good

4. Do you include any dietary supplements? YES NO

5. Is weight loss one on your primary exercise goals? YES NO

Do you have any pre-existing conditions which restrict or limit you physically?

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