Profiles & Assessment Forms Health and Lifestyle Questionnaire by PTontheNET Library | Date Released : 29 Sep 2004 0 comments Print Close All of the information you provide in this questionnaire is strictly confidential and will become part of your training record. Client Name (please print):__________________________ If you tick "yes" to any of these questions, please provide details such as date of occurrence, frequency, intensity, etc. Do you suffer from back pain? Yes No Are you sensitive to touch/pressure in any area? Yes No Do you have tension, numbness or pain in a specific area? Yes No Do you experience frequent headaches? Yes No Are you pregnant? Yes No If yes, when are you due: Do you have high blood pressure? Yes No Do you have high cholesterol? Yes No Are you epileptic? Yes No Have you ever had surgery? Yes No Have you ever broken any bones? Yes No Do you experience stiff, swollen or painful joints? Yes No Do you have difficulty sleeping? Yes No Do you experience fatigue or lack of energy? Yes No Do you experience cold hands or feet? Yes No Have you ever been advised by a physician to avoid any type of exercise? Yes No /li> Have you ever been knocked unconscious or suffered a concussion? Yes No Do you (or does someone in your family) have a cardiac condition? Yes No Do you have any allergies? Yes No Are you currently taking any medications? Yes No Have you ever seen a Nutritionist/Registered Dietician? Yes No Do you smoke or have you smoked in the past? Yes No Do you live with a smoker? Yes No Do you drink coffee? Yes No What is your "chief complaint" (if applicable): Please state how long you have had this complaint, when you first noticed it and what you feel may have caused the problem: How does your "chief complaint" affect you on a day-to-day basis? Please state what you CAN and CANNOT do any more. Are the symptoms brought on by certain activities or positions? Yes No Is the pain worse at certain times of day? Yes No Do specific activities or positions alleviate your symptoms? Yes No Do you have an ergonomically set up desk/workstation? Yes No How many hours do you spend in front of a computer? On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career. On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your personal life. What is the heaviest you have weighed, and how old were you at that time? What previous treatment(s) have you tried? Please state what and when. Have you ever had any of the following: physical therapy, chiropractic, massage, acupuncture, Feldenkrais, rolfing, Alexander technique, Other? Please elaborate. What time do you usually go to bed at night and wake up in the morning? How many meals do you eat each day? List the number and time of day you usually eat these meals. How many days do you have to commit towards working out? Are there any areas of your body you want to specifically work on? 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