HISTORY All information is strictly confidential. Name * First Name Last Name Email * Phone * (###) ### #### Height * Weight * What is your occupation? Do you partake in any recreational activities (golf, tennis, skiing, etc.?) If yes, please explain. * Have you ever had discomfort, pain, or injuries (ankle, knee, hip, shoulder, back, etc.)? If yes, please explain and include timing. * If "yes" to the above, what is the discomfort or pain preventing you from doing? What could you do prior that you can no longer do, and that you Want to do? Have you had any surgeries? If yes, please explain and include timing. * Have you ever been diagnosed with a chronic disease, such as heart disease, hypertension, diabetes, etc.? If yes, please explain. * Please list medications you currently take: Do you Currently have any issues in the following areas: * Cardiovascular (high BP, racing pulse, etc.) Respiratory Joint Pain, Swelling, Arthritis Neurological (numbness, headache, etc.) None at this time Do you experience any of the following regularly or somewhat regularly? * Dizzy / vertigo Lose balance / bump into things Blurry or double vision Back of hip pain Tight IT Band Discomfort on the same side of your body, multiple and varying locations Anxiety or depression Motion Sickness Insomnia Difficulty concentrating Tinnitus Cannot squat or lunge Reading deficits None at this time In times of stress, what is your PRIMARY "go to" for calming: * Go for a walk, any type of movement Curl up in the blanket, watch a movie, binge watch Play video games, read a book, anything to challenge my brain Is there anything else you would like to share with your trainer? Thank you! Your trainer will be in touch to further discuss during your initial consult.
