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?

Other
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?
If Yes, Please Provide Details.
3. Activity and Lifestyle
Do You Engage In Regular Physical Activity Or Sports
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?
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?
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):
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?
If Yes, Please Provide Details
5. Medical History
Do You Have Any Medical Conditions Or Injuries We Should Be Aware Of?
If Yes, Please Provide Details.
Are You Currently Taking Any Medications?
If Yes, Please List Them.
Have You Had Any Surgeries In The Past 12 Months?
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
Date:

DayMonthYear
Should be Empty:

FUNCTIONAL BODY CLINIC

1. General Information

2. Primary Complaint

3. Activity and Lifestyle

4. Goals for Treatment

5. Medical History

6. Consent