Health & Fitness History

Health & Fitness History

Enso Bodywork
DateTime
Please complete the following in as much detail as possible. Providing an accurate health history helps me, your practitioner, to provide the best care I can. Witholding information can be deterimental to both of us.

This form is best filled out on a laptop, desktop or larger mobile device.
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Occupation
Height
Weight
Age
Age: Date of Birth: Date

Height: Weight:
Please indicate any current conditions and provide details in the following section.

Abdominal PainAlcohol (specify daily average below)AllergiesAnxietyArthritis - specify rheumatoid or osteo belowCancerChest painConstipationContact lensesDepressionDiabetesDigestive concernsEpilepsyFatigue (Specify time of day below)Frequent colds or fluHeadachesHeart DiseaseHernia or uptureHigh or Low blood pressureKidney diseaseLung diseaseNeurological concernsNicotine (specify daily average below)Painful feetPregnancyPMSTMJ DisorderTuberculosisSinusitisVaricose veins/PhlebitisOther
Please provide clarification on any conditions which were indicated above
Are you under the care of a medical practitioner? (MD, chiropractor, naturopath, psychologist,etc.) If yes, please explain your condition.
List any medications you are using and their purposes.
Have you been hospitalized or had any major surgeries? Please explain.
Do you currently have any infectious conditions or diseases? Please explain.
Please describe any skin conditions you currently have. (rashes, athletes foot, eczema, etc)
Is there anything relating to your health which you are concerned about? Specific pains?

Please describe your history of accidents, injury, pain, soreness, stiffness, immobility, etc.,(include whiplash, scoliosis, broken bones, etc.) affecting the following areas:

	Detail
Cervical spine and head (neck, head)
Thoracic spine (upper, mid back)
Lumbar spine (lower back)
Sacrum and hips
Joints (elbows, shoulders, ankles, knees, etc. - sprains, bursitis, swelling)
Extremities (legs, arms - breaks, sciatica, carpal tunnel)
Other

Please describe any significant accidents, diseases, or ailments which you have experienced in the past five years that are not included above.
Relationships: Mother alive? Father alive?
Describe the significant relationships in your life.
Sleep: Average hours of sleep per night  blanks
On rising:   Refreshed   Tired

Exercise (list activities):
Hours per day (avg):
Hours per week (avg):
Please describe your diet
How is your health preventing you from doing what you want to do with your life?
Is there anything else you wish to add?
Should be Empty:

Health & Fitness History

Age: Date of Birth: Date Height: Weight:

Age: Date of Birth: Date

Height: Weight: