coffeecup web form

Client Assessment Form

Name

Birth Date

Parent/Guardian

Address

City

Phone (Home)

Phone (cell)

Phone (work)

Email

Phone (Parent/Guardian)

Email (Parent/Guardian)

Emergency Contact

Emergency Contact Phone

Physician or Physiotherapist

Physician/Physio Phone

How did you hear about the Fitness Fix?

Your Current Injury

What is your current Injury or Pain?

What movements or activities are limited?

What, if anything makes your condition worse?

What, if anything makes your condition better?

Do you have a head concussion, currently or have had in the past?

Yes No

Are you presently receiving treatment

Yes No

May we contact him/her?

Yes No

Therapists name

Phone Number

Type of treatment

Are you currently under a doctors care?

Yes No

May we contact him/her?

Yes No

Your Medical History (Pre-existing conditions)

Do you currently have, or have you in the past had complications with any of the following (Check all that Apply):

Chronic Illness or disease

Has your physician ever advised you against exercise?

Yes No

If Yes when and why

Has your physician ever said you have heart troubles?

Yes No

Do you smoke or have you quit in the last 6 months?

Yes No

Do you consume alcohol on a regular basis?

Yes No

Are you currently pregnant?

Yes No

If you have been pregnant, when?

C Section?

Yes No

If you have been pregnant, were there any pregnancy related health issues?

Your Medications and Health Care

Please list any medications taken on a regular basis:

Do you habitually consume over 3-4 cups of coffee/cans of soda per day?

Yes No

How would you describe the emotional climate of your home? Scale: 1=very bad, 10=very good

Please rate the level of stress at your work or in other aspects of your life: Scale: 1=very bad, 10=very good

Please describe the nature of your stress:

Please describe your sleep (hours, quality, etc.)

Do you have fatigue during the day?

Yes No

What is your occupation?

What are your main occupational activities? (check all that apply):

other occupational activities

Your Fitness History and Goals

Have you ever participated in a fitness program?

Yes No

If yes, when

Have you been sedentary (inactive) for the past year or more?

Yes No

How often do you exercise?

If exercising, please briefly describe your exercise program:

How would you rate your present fitness level?

Please list the goals you would hope to achieve with a specialized fitness/treatment program

How many times per week would you reasonably like to incorporate exercise?

Approximately how long in each session?

Please list the equipment/facilities you have access to:

Please include any other information that may help us to optimize your training and recovery plan:

Your Orthopedic History

Do you wear orthodics?

Yes No

Do you have, or have you in the past had any of the following complications (check all that apply):

Neck

Burners/stingers Fractures/sprains/strains

Elbow

Fractures Sprains Dislocations Inflamation

Lower Leg

Shin Splints Achillies Pain Fractures

Shoulders

Seperations Fractures/sprains Dislocations

Hand Wrist Finger

Numbness/pain Fractures/sprains Dislocation

Ankle

Sprain Fractures Dislocation

Arm

Numbness/Pain Fractures

Feet/Toes

Sprains Fractures/Dislocations

Spine/Back

Disc Ruptures Fractures Pain/Spasm

Thigh

Muscle Strains Muscle Contusions Fractures

Pelvis Hip

Strains/contusions Fractures/Dislocations

Knee

If you have any of the above or other, please list and explain:

Have you had any surgeries performed?

Yes No

Surgical Procedures and Date

Is there anything that you feel is important that has not been covered?

Thank you for completing the client profile. Please hit submit and you will receive a confirmation email.