Client Information
Name
Age
Date of Birth
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Month
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Day
Year
Email
Phone Number
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Area Code
Phone Number
Service(s) interested in
Emergency Contact Details
** Necessary if something occurs while we are on a virtual call/ in-person session **
Contact Person Name
Primary Phone Number
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Area Code
Phone Number
Medical Data
Are you currently taking medications? If yes, then please list the medications and the reasons why are you taking them.
Medical history: Currently pregnant? Prior surgeries? Respiratory, Autoimmune, Cardiovascular, Neuromuscular diagnosis? Diabetes? History of cancer?
What is your primary area of concern? Specific injury? Chronic pain? Trauma related?
Where are you in your activity level now (sedentary?moderately active? very active?). What do you do now to move?
What do you want to get out of this? What are your goals while working with Movement rX?
What type of equipment (if any) do you use? i.e kettlebell, barbell, dumbbells, body weight
Acknowledgment, Authorization and Waiver
I authorize Xander Boger with Movement rX to perform the virtual/ in-person assessment
I authorize consent for treatment for musculoskeletal related conditions and movement limitations
I authorize that I am 18 years and older
I understand that without compliance to program including check-ins, follow-ups, performance of program, I may not achieve the goals that I desire.
I acknowledge that all information I provided in this form is true and accurate.
I agree to inform Xander Boger with Movement rX of any new diagnoses pertinent to my treatment, changes in medical conditions, updates that could affect my performance in treatment plans
I acknowledge that I am responsible for my decisions and movements that I perform on a daily basis and while performing exercises prescribed with Movement rX
Client Signature
Date Signed
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Month
-
Day
Year
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