Client Intake

Name

First NameLast Name

Birthdate

Date

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Email

example@example.com

Emergency Contact Person

Emergency Contact Phone

Please enter a valid phone number.Format: (000) 000-0000.

PART 1 - Medical History

Please answer each question carefully and completely. This is very important information and will contribute significantly to the development and implementation of your personal health and fitness program.

1. Who are your primary and secondary care medical providers? (Family physician, OBGYN, internist, psychiatrist, chiropractor, etc.)

Please format as: FULL NAME / ADDRESS and PHONE / REASON FOR SEEING PROVIDER. Each provider should have its own line.

2a. Please list any medications you are currently taking.

Please format as:MEDICATION / DOSAGE / WHY AND HOW LONG HAVE YOU BEEN TAKING THIS MEDICATION. Each medication should have its own line.

2b. Please list any meds you have taken in the past for more than six months but no longer take and why start and stop.

3. Do you take any nutritional/dietary supplements? If so, please list below.

Please format as: NAME OF SUPPLEMENT / DOSAGE / WHY & HOW LONG HAVE YOU BEEN TAKING THIS SUPPLEMENT. Each supplement should have its own line.

Do you now have or in the past suffered from any of the following?

a. Has your Doctor said, or do you have a history of, heart problems, chest pain or stroke

b. Has an immediate family member (parent/sibling) had a heart attack, stroke or cardiovascular disease before the age of 55 yrs old?

c. Do you frequently have pains in your heart and/or chest when you do physical activity?

d. Do you lose balance because of dizziness or do you ever lose consciousness?

e. Is your doctor(s) currently prescribing drugs for blood pressure or heart condition? See Question #2

f. Are you over the age of 65 and not accustomed to vigorous exercise?

g. High Cholesterol or HDL: LDL imbalance

h. Do you currently smoke? Cigarette, cigar, pipe smoking, etc.

If yes to h, how much and how long?

i. Obesity

j. Asthma or Breathing trouble

k. Have you ever had a stroke or heart attack?

l. Are you a male greater than 45 yrs old? Are you a female greater than 55 yrs old?

m.(Females) Pregnancy currently or within last 12 months?

If yes to m, how many children have you had?

n. Learning disabilities or cognitive challenges

o. Do you consume any alcoholic beverages? (Beer, wine, liquor, etc.)

If yes to o, please indicate in ounces how much alcohol you consume weekly (include beer, wine, liquor)

p. Do have difficulty swallowing food or chewing food?

q. Is there any reason not mentioned thus far to preclude you from regular exercise activity?

r. Do you have urinary incontinence? (bladder control loss w/ coughing, sneezing, exercising, laughing)

Please elaborate here if you checked yes for letters a c d j n and O

Do you use any nonprescription drugs? (marijuana, cocaine, etc)

5. Please provide your most recent blood panel and any radiological reports you have from x-rays or MRI's.

Please complete the following information as completely and thoroughly as possible. This is an extremely important section of this questionnaire.

6. Trauma/Injury/Surgery History (every significant physical pain you have experienced) includes even what you might consider minor, non-medically treated injuries.

Eyes, mouth, throat/tongue injury, surgery, ears, hearing (i.e. Clicking jaw, nose, concussion, ears, hearing, etc.)

Include age when experienced

Knees Patella, ACL, Tendonitis

Include age when experienced

Ankle, Feet Toes, Plantar Fasciitis, Bunions, Orthotics

Include age when experienced

Shoulder, Scapulae, Collar bone, Rotator cuff

Include age when experienced

7. Have you had any cosmetic/plastic surgery? Please describe below. (breast augmentation, tummy tuck, botox)

8. Diagnosed Diseases Please Provide all medical reports (X-rays/MRI/CT Scan)

Orthopedic (i.e. Spinal fusion, Knee joint replacement)

Metabolic (ie Diabetes Hypothyroid)

Neurological (ie Stroke, Parkinsons)

Dental Work (Braces/Night Bite Plates, Appliances, orthodontics)

9. What is your occupation?

Physical

How long per day?

How long have you been under this stressor? (Years)

Emotional

10. Please list below the severity of your current physical condition/pain/discomfort (#1 is the worst or greatest concern)

#1

#2

#3

#4

11. If you feel that you are experiencing unusual levels of stress in one or more of the following areas, please select "Yes." If not, select "No":

Home

Work/School

Financial

12. Please describe a typical day of activity for you. Example: "My morning Starts at 6:00 am and I drink a cup of coffee and drive to work. I sit at a desk until noon and order lunch from a local restaurant. I typically work through lunch. I sit at a computer and talk on the phone and end my work day at 6pm. I drive home, pick up my kids and eat dinner around 7pm. I do house chores and am in bed by 11pm."

13. Do you play a musical instrument? If so, which instrument, how long, how many hours of practice/week?

14. Are/Were you a high school or college athlete? Please list sports and positions

15. Please describe your footwear. What do you wear the most throughout the week?

16. Are you sleeping well?

17. What are your daily work duties/demands?

18. What physical activities and/or physical positions can you not perform without discomfort or significant tension? (I.e., kneeling down, reaching overhead)

19. What self-care strategies do you currently use to manage your own health and why? (Ice packs, stretching, acupuncture, magnets, heating pad, massage, etc)

20. Do you feel that with each passing year you are getting healthier or unhealthier?

1. Have you consulted with a physician regarding diet and exercise? If yes, please describe the recommendations

2. Have you in the past, or are you currently following a special diet or eating program? If so, please describe.

3. Please list and rate the goals for your movement/exercise program by how close or far you are to reaching them right now; select a number for each goal listed.

Rows	Proximity (1 if far, 10 is done)
Goal 1
Goal 2
Goal 3

Goal #1

Goal #2

Goal #3

4. Please describe your current exercise program. Include how often:

How long each session

Type of exercise

Where you exercise

5. If you are currently exercising what do you think would happen if you stopped for 3-4 weeks?

6. Have you started exercise programs in the past or joined gyms and stopped? Why?

Muscle Auditor LLC requires 24-hour notice if you are unable to keep a scheduled appointment. If prior notice is not given, you will be charged in full for the missed appointment.

Muscle Auditor is 100% dedicated to improving the way your body performs and feels on a daily basis, and expect your commitment in return.

Signing this agreement confirms your consent to these terms.

Signature

Date

Health History and Pre-Exercise Questionnaire

Fitness and Wellness