Client Activity and Recovery Screen
Name
*
Date
*
/
Month
/
Day
Year
Date
Occupation
What do you do for work?
Does your occupation require extended periods of sitting?
Yes
No
Does your occupation require repetitive movements? (If YES, please describe)
Yes
No
Does your occupation require heavy lifting?
Yes
No
Does your occupation require you to wear shoes with a heel (e.g., dress shoes)?
Yes
No
Does your occupation cause you mental stress?
Yes
No
Personal
Do you have any stressors in your personal life? (If YES, please describe)
Yes
No
Do you partake in any recreational physical activities (golf, skiing, etc?) (If YES, please describe)
Yes
No
Do you have any additional hobbies (reading, video games, etc? (If YES, please describe)
Yes
No
Health
Have your ever had any surgeries? (If YES, please describe)
Yes
No
Have you ever had an injury to your ankles, knees, back, or shoulders? (If YES, please describe)
Yes
No
Sleep
Do you typically get 8+ hours of sleep per night?
Yes
No
Is sleep often disrupted or do you have trouble falling and staying asleep?
Yes
No
Do you feel energized throughout the day and prior to activities? (If NO, please explain)
Yes
No
Do you need to consume more than your usual dose of caffeine in order to stay awake and perform at your best?
Yes
No
Recovery
How many cumulative minutes of psychological relaxation do you achieve per day
How do you achieve this relaxation? (ex. reading, meditation, breathing exercises)
On a scale of 1 to 10, how stressed do you typically feel? (1= No Stress; 10= Extremely Stressed)
Nutrition
Do you consume nutritious pre-training meals/snacks? (If YES, please describe)
Yes
No
Do you consume nutritious post-training meals/snacks? (If YES, please describe)
Yes
No
Hydration
Do you feel you are drinking enough fluids?
Yes
No
How many ounces of water do you regularly consume per day?
Pre-Activity/Warmup
How many days per week do you use myofascial rolling, trigger point massage, stretching, yoga, hot-cold modalities, targeted strengthening, or other movement strategies before movement?
Post-Activity/Cooldown
How many days per week do you use myofascial rolling, trigger point massage, stretching, yoga, hot-cold modalities, or other recovery strategies after movement?
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