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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