Corrective Exercise Intake Form

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Gender

Occupation

Mobile Phone

Home Phone

Work Phone

Email

Source of Referral

Address

City

Country

Province / State

Postal / Zip Code

Emergency Contact

Emergency Phone

Relationship

Doctor's Name

Doctor's Phone

Doctor's Address

Please describe your present state of health:

What is your reason for seeking corrective exercise and movement?

Do you have any allergies? If yes, what are they?

Do you experience pain in any part of hour body? If yes, explain and define as acute, chronic or occasional.

Do you have spine or disc trouble? If yes, please explain:

Does you occupation or daily routine require or include the following:

Extended periods of sitting?

Repetitive movements?

Heavy lifting?

If you checked boxes to above question regarding sitting, repetitive movements, or heavy lifting, please explain

Do you have any stressors in your personal life or occupation? If so, explain.

How would you describe your current stress level? What do you find is effective for relieving stress for you?

How many hours of sleep do you get per night? Please describe your current sleep profile:

Describe in detail any other issue, experience, health or medical condition that may be having an impact on hour health:

Please share your recreational activities and exercise on a weekly basis:

List your goals you wish to achieve through your corrective exercise and movement program:

Please describe your previous experience with corrective exercise, if any:

Do you have any other comments and/or concerns? If so, please explain:

Please list all medications and supplements (over the counter and prescription) you are currently taking and your reason for taking:

Please list all surgeries past and present:

Please list all injuries past and present: