Client-History-and-Health-Questionaire

Client History and Health Questionnaire

Please fill out this form as fully, accurately, and honestly as possible prior to our session. Small details are just as important as major issues in assessing body systems. Mental, emotional, and social aspects of your life all play a role in your overall health. Please mention any stress you are experiencing prior to or during our session.
Name
Date of first visit

MonthDayYear
Date
Address
Phone #
Age
DOB
Email
example@example.com
Height
Weight
Marital status
Occupation
Number of children and ages
Handedness
General Health History List in order of most important to least important any pain or dysfunction present in your body today, as well as the approximate date of onset: 1.
1
2
3
Have you seen a general practitioner or specialist for any of these problems
Was there any treatment or diagnosis given If yes what was it
On a scale of 1-10 (with 10 being the most committed), how committed are you to achieving your health goals?
Has the condition changed with treatment
On a scale of 1-10 with 10 being the most energy how would you rate your energy level in general
Please list all medications you are currently taking
Are you experiencing any side effects?
Do you have depression or anxiety
Do you have difficulty falling asleep or staying asleep
Can you fall back asleep easily
Do you wake up at night to go to the bathroom
Do you drink alcohol If yes please note frequency
Do you currently smoke If yes please note frequency
Do you feel extreme stress or pressure from day to day
How much water do you drink per day
Do you drink coffee If yes please note frequency
Do you exercise regularly? If so what type?
How many meals do you eat per day on average
Please list any surgeries (major or minor) you have undergone:
Have you ever experienced any of the following? Check all that apply:

Hospitalization/ Car accidentExcessive hair lossTiredness/weaknessFever/chills (for unknown reasons)Sprains or dislocationsNeck or low back painArm/leg problems, numbness/tinglingJoint pain or disfunction, muscular pain, arthritisBroken bonesDifficulty walkingFrequent muscle twitching, ticksLigament sprains, muscle strainsCartilage disfunction or tearsDizziness, vertigo, frequent headaches, migraines, loss of balance
Have you ever been diagnosed with cancer? If yes, what type?
Difficulty breathing Nose surgery or reconstruction
Frequent sore throats Gum problems Grinding of teeth, TMJ, clicking jaw Dental crowns, bridges, mouth work Gland swelling Braces (current or past)
High blood pressure Heart murmurs Heart palpitations Gastrointestinal System irregular heartbeat
Varicose veins
Frequent constipation Frequent diarrhea Abdominal pain Colitis, Crohn's disease, or ulcers Frequent nausea/vomiting
Chronic coughing, Cardiovascular System and Peripheral Vascular System Pain while breathing, Shortness of breath
Frequent heartburn Frequent indigestion or gas Frequent cramps
Prostate issues or enlargements Fibroids, cysts, or endometriosis Frequent cramping Heavy flow during period
If necessary, I allow Maria Rigo to discuss with my health care provider or physical therapist the appropriateness of MELT training for my general health and wellness and I understand that MELT is not a replacement for medical treatment or medical diagnosis. I release Maria Rigo from any kind of claim or injury resulting from any act or omission during MELT practice or treatment. being aware of my own health and physical condition:

1)I certify that I have been informed of and understand that any exercise and/or fitness activities involve a risk of injury, and that I am voluntarily participating in these activities with understanding and appreciation of the risks involved. I hereby agree to expressly assume and accept any and all risks of injury regardless of severity.
INITIALS
2) I understand that all information and services provided by Maria Rigo are of a general nature and are provided for educational purposes only. None of the information or services provided by Maria Rigo are to be taken as medical or other health advice pertaining to any specific health or medical condition that I have or may have had. The information and services provided by Maria Rigo are not a diagnosis, treatment plan or recommendation for a particular course of action regarding my health and are not intended to provide specific medical advice.
INITIALS
3) I understand that I am learning MELT techniques for my own self-care and I can not teach any MELT techniques to any other group or population in a class setting until appropriately trained and licensed by Longevity Fitness. I understand that there are potential legal consequences for teaching this material directly or by teaching the techniques and calling it by another name.
INITIALS
Client Signature

Clear
Date

MonthDayYear
Date
Cancellation Policy In order to provide all of our clients with the opportunity to schedule sessions at their most convenient times, we ask that if you must cancel your session, that 24 hours notice is given prior to scheduled time. If you must cancel less than 24 hours prior to your scheduled session time you will be charged for your session.
Should be Empty: