Z-Health Intake Form
Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Date
*
-
Month
-
Day
Year
Date
Birthdate
*
-
Month
-
Day
Year
Date
Occupation
Do you exercise regularly? And what kind of physical activities do you engage in?
What kind of sport or activities did you like when you were younger?
Is there anything you would like to do that you are currently unable to? If so, what is that?
*
What are your goals in us working together?
*
How would you be able to tell that this partnership has been successful?
*
Health History Questions
Do you currently have any medical diagnoses? If so, please describe.
*
Are you currently taking any medications? If so, please describe.
*
Do you have any of the following (check all that apply):
Scars
Peripheral neuropathy
Nerve damage
Tatoos
Previous orthopedic injuries
I love compression gear
Please explain as best you can the event(s) resulting in the above.
Do you currently experience any of the following (check all that apply):
Chronic muscle weakness
Nerve pain
Joint instability
Muscular atrophy
Numbness and tingling
Overstretch injury
Abrerrant sensations
If so, please describe.
Have you ever experienced any of the following (check all that apply):
Whiplash/seatbelt trauma
Concussion/mTBI
Stenosis
Disc injury anywhere in your spine
Seatbelt trauma
Bilateral extremity issues
Muscle weakness
Visceral dysfunction
If so, please describe.
Check all that apply:
Balance issues
Must use handrails
Careful with stairs
Sway to one side while walking or standing
Prone to falls
Unsteady in the dark
Scoliosis
Terminal tremors
Clumsiness - hands & feet
Tripping
Decreased tone in limbs
Increased heart rate
Orthostatic hypotension
Vertigo
Cognitive dysfunction
Dizziness
Disorientation
Poor spinal stability
Back muscles fatigue easily
Motion sickness
Anxiety/dislike crowds
Tinnitus
If so, please describe.
Check all that apply:
High blood pressure
High heart rate
Arrhythmia
Sweaty hands or feet (especially on one side)
Slow moving digestion
Light or sound sensitivity
None
If so, please describe.
Check all that apply:
Hypertension
High heart rate
Sweat more easily
Cold hands and/or feet
Decreased gut motility
Pain and injuries are all on the same side
Light and/or sound sensitivity
If so, please describe.
Check all that apply:
Repetitive head trauma
Mood swings
Chronic pain
Burning or aching sensation
Loss of sensation in multiple areas
Movement tics
Motor Learning deficits
Impairment of executive function
Apathy
Problems with word retrieval
Slow movements
Difficulty initiating movements
Essential tremors at rest
Cramping of hands and/or feet
If so, please describe.
Check all that apply:
IBS (Irritable Bowel Syndrome)
Chronic GERD (Gastro Esophogeal Reflux Disorder)
Eating disorder
Anxiety
Motion sickness
Depression
PTSD
Chronic gut distension or bloating
Inappropriate crying or laughing
Difficulty swallowing
Chronic immune system issues
ADHD
Pelvic floor pain, weakness, or incontinence
Overawareness of heart beat
Lack of body ownership
Exercise intolerance
Vertigo/vestibular issues
If so, please describe..
Check all that apply:
Enjoys visually stimulating environments
Loss of color vision
Likes playing ball sports
Likes sports that don't use balls
Floaters in the eyes
Cataracts or glaucoma
Eye surgery
Wears glasses or contacts
Halos in visual fields
Lasik surgery
If so, please describe
Check all that apply:
Avoid noisy enviroments
Difficulty understanding imprecise speech pattern
Inabilty to localize sound
Auditory hallucinations
Need to look at speaker's mouth to understand
Difficulty understanding meaning of speech
Monotone speech
Memory deficits
Confusion about time
Difficulty with dates
Cannot mentally relive day
Altered circadian rhythms
Olfactory deficits
Cannot remember addresses
Diffeculty with visual memory
Difficulty to rembember faces
Often misplace itmes (keys)
Difficulty linking names to faces
Difficulty remembering words
Difficutly remembering numbers
Hard to be on time
If so, please describe
Left side dominant 97%
Reading deficits
problems with writing
Right/left confusion
difficulty with calculations
History of dyslexia
Difficulty recognizing shapes
Simple drawings are difficult
Difficulty interpreting maps
Poor handwriting
Mental calculation difficult
Hard to "find" words
Sensory loss on one side
Frequently bump inot things
Hypersensitive to touch/pain
Lack of spatial awareness
Localized tingling - periodic
If so, please describe
Check all that apply:
Decreased focus capacity
Decreased attention span
Poor organizational abiliy
ADHD
Difficulty with initiating tasks
Excessive risk taking
Lack of clear goals
Difficulty finishing things
Apathy
Perseveration
Lack of behavioral restraint
Inabilty to create logical sequences
Low mood
Depressive episodes
Emotional instability
Difficulty making decisions
Difficulty initiating movement
Arm or leg heaviness
Arm or leg muscle tension
Reduced muscle endurance
Noticeable side-to side difference in strength or muscle tension
Poor manual dexterity
Difficulty following a rhythm
Poor core stability
Bladder control problems
If so, please describe.
Please select which of the following best describes you (check all that apply):
Seldom or never bump into things
Often injure one side of the body
Hypersensitive to pain or touch
Enjoy massages and bodywork
Easy time reading maps
No problem telling right from left
History of dyslexia
Are you currently taking any weight management medication?
If so, please describe.
Injury and Surgery History
Have you ever had surgery? If so, please describe.
Have you ever had dental surgery (cavities, root canals, braces, retainer, etc)? If so, please describe.
Have you ever been in a car accident? If so, please describe.
Any other injury, surgery or health condition that is not mentioned before:
Fuel Section
Tell me a little bit about your current diet. What do you typically eat?
Have you ever tried any other diets? If so, which ones?
Do you, or have you ever fasted regularly? If so, please describe.
Do you have a history of thyroid issues? If so, please describe.
Any food sensitivities or allergies? If so, please describe.
Do you have any breathing related problem? If so, please describe.
Who are you?
What is your favorite movie?
What is your favorite food?
What is your favorite place to travel to?
What do you do for fun?
Submit
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