FUNCTIONAL BODY CLINIC

FUNCTIONAL BODY CLINIC

Health Questionnaire
1. General Information
Full Name:*
Email:*
example@example.com
Mobile:*
D.O.B*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal Code
Occupation:*
Emergency Contact: (Name & Contact Number)*
How did you hear about my practice?

Google SearchSocial Media (e.g., Facebook, Instagram)Referral (e.g., friends, family, or other clients)Flyers/PostersWebsiteWord of MouthOther
2. Primary Complaint
Primary Complaint: (What is the primary issue you’d like us to address?)
How Long Have You Been Experiencing This Issue?
How Severe Is The Discomfort Or Pain On A Scale Of 1-10?
Does This Issue Affect Your Daily Activities or Work?

YesNo
If Yes, Please Provide Details. *
3. Activity and Lifestyle
Do You Engage In Regular Physical Activity Or Sports

YesNo
If Yes, What Type Of Activity Or Sport, And How Often*
How Would You Rate Your Current Stress Levels (1 = Low, 10 = Very High)
Do You Have A Physically Demanding Job Or Lifestyle?

YesNo
If Yes, Describe The Nature Of Your Activities*
If yes, please describe your typical daily posture or activities (e.g., desk work, standing at a counter, driving for extended periods), Including Durations?*
Do You Spend Long Hours Sitting Or Standing?

YesNo
Meaningful Tasks: What specific activity or movement is most important to you that you currently find difficult or want to improve? (Examples: sitting comfortably, walking, climbing stairs, running, driving, or sleeping without pain.
4. Goals for Treatment
What Are Your Primary Goals For Treatment? (Select All That Apply):

Pain relief or recovery from an injury.Improving sports performance or recovery from physical activity.Preventing future injuries and supporting long-term physical health.Relaxation and stress relief.Maintaining flexibility, mobility, and overall physical health.
Are There Specific Areas Of Your Body You'd Like To Focus On?
Do You Have A Specific Event Or Activity You're Preparing For?

YesNo
If Yes, Please Provide Details*
5. Medical History
Do You Have Any Medical Conditions Or Injuries We Should Be Aware Of?

YesNo
If Yes, Please Provide Details.*
Are You Currently Taking Any Medications?

YesNo
If Yes, Please List Them.*
Have You Had Any Surgeries In The Past 12 Months?

YesNo
If Yes, Please Provide Details.*
6. Consent
I confirm that I fully release and indemnify Adrian Wildborne from any liability for injuries or medical complaints (physical and/or mental) that may arise as a result of the therapy services provided. This includes cases where I have failed to disclose any medical conditions that I am aware of or should reasonably have been aware of at the time of completing this health questionnaire.
Signed*

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FUNCTIONAL BODY CLINIC

1. General Information

2. Primary Complaint

3. Activity and Lifestyle

4. Goals for Treatment

5. Medical History

6. Consent