Z-Health Intake Form

Z-Health Intake Form
Name*

First NameLast Name
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Birthdate*

MonthDayYear
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):

ScarsPeripheral neuropathyNerve damageTatoosPrevious orthopedic injuriesI 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 weaknessNerve painJoint instabilityMuscular atrophyNumbness and tinglingOverstretch injuryAbrerrant sensations
If so, please describe.
Have you ever experienced any of the following (check all that apply):

Whiplash/seatbelt traumaConcussion/mTBIStenosisDisc injury anywhere in your spineSeatbelt traumaBilateral extremity issuesMuscle weaknessVisceral dysfunction
If so, please describe.
Check all that apply:

Balance issuesMust use handrailsCareful with stairsSway to one side while walking or standingProne to fallsUnsteady in the darkScoliosisTerminal tremorsClumsiness - hands & feetTrippingDecreased tone in limbsIncreased heart rateOrthostatic hypotensionVertigoCognitive dysfunctionDizzinessDisorientationPoor spinal stabilityBack muscles fatigue easilyMotion sicknessAnxiety/dislike crowdsTinnitus
If so, please describe.
Check all that apply:

High blood pressureHigh heart rateArrhythmiaSweaty hands or feet (especially on one side)Slow moving digestionLight or sound sensitivityNone
If so, please describe.
Check all that apply:

HypertensionHigh heart rateSweat more easilyCold hands and/or feetDecreased gut motilityPain and injuries are all on the same sideLight and/or sound sensitivity
If so, please describe.
Check all that apply:

Repetitive head traumaMood swingsChronic painBurning or aching sensationLoss of sensation in multiple areasMovement ticsMotor Learning deficitsImpairment of executive functionApathyProblems with word retrievalSlow movementsDifficulty initiating movementsEssential tremors at restCramping of hands and/or feet
If so, please describe.
Check all that apply:

IBS (Irritable Bowel Syndrome)Chronic GERD (Gastro Esophogeal Reflux Disorder)Eating disorderAnxietyMotion sicknessDepressionPTSDChronic gut distension or bloatingInappropriate crying or laughingDifficulty swallowingChronic immune system issuesADHDPelvic floor pain, weakness, or incontinenceOverawareness of heart beatLack of body ownershipExercise intoleranceVertigo/vestibular issues
If so, please describe..
Check all that apply:

Enjoys visually stimulating environmentsLoss of color visionLikes playing ball sportsLikes sports that don't use ballsFloaters in the eyesCataracts or glaucomaEye surgeryWears glasses or contactsHalos in visual fieldsLasik surgery
If so, please describe
Check all that apply:

Avoid noisy enviromentsDifficulty understanding imprecise speech patternInabilty to localize soundAuditory hallucinationsNeed to look at speaker's mouth to understandDifficulty understanding meaning of speechMonotone speechMemory deficitsConfusion about timeDifficulty with datesCannot mentally relive dayAltered circadian rhythmsOlfactory deficitsCannot remember addressesDiffeculty with visual memoryDifficulty to rembember facesOften misplace itmes (keys)Difficulty linking names to facesDifficulty remembering wordsDifficutly remembering numbersHard to be on time
If so, please describe
Left side dominant 97%Reading deficitsproblems with writingRight/left confusiondifficulty with calculationsHistory of dyslexiaDifficulty recognizing shapesSimple drawings are difficultDifficulty interpreting mapsPoor handwritingMental calculation difficultHard to "find" wordsSensory loss on one sideFrequently bump inot thingsHypersensitive to touch/painLack of spatial awarenessLocalized tingling - periodic
If so, please describe
Check all that apply:

Decreased focus capacityDecreased attention spanPoor organizational abiliyADHDDifficulty with initiating tasksExcessive risk takingLack of clear goalsDifficulty finishing thingsApathyPerseverationLack of behavioral restraintInabilty to create logical sequencesLow moodDepressive episodesEmotional instabilityDifficulty making decisionsDifficulty initiating movementArm or leg heavinessArm or leg muscle tensionReduced muscle enduranceNoticeable side-to side difference in strength or muscle tensionPoor manual dexterityDifficulty following a rhythmPoor core stabilityBladder control problems
If so, please describe.
Please select which of the following best describes you (check all that apply):

Seldom or never bump into thingsOften injure one side of the bodyHypersensitive to pain or touchEnjoy massages and bodyworkEasy time reading mapsNo problem telling right from leftHistory 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?
Should be Empty:

Z-Health Intake Form

Health History Questions

Injury and Surgery History

Fuel Section

Who are you?