PT on the Net Research

Health and Lifestyle Questionnaire

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.

  1. Do you suffer from back pain? Yes  No 
  2. Are you sensitive to touch/pressure in any area? Yes  No 
  3. Do you have tension, numbness or pain in a specific area? Yes  No 
  4. Do you experience frequent headaches? Yes  No 
  5. Are you pregnant? Yes  No 
    • If yes, when are you due:
  6. Do you have high blood pressure? Yes  No 
  7. Do you have high cholesterol? Yes  No 
  8. Are you epileptic? Yes  No 
  9. Have you ever had surgery? Yes  No 
  10. Have you ever broken any bones? Yes  No 
  11. Do you experience stiff, swollen or painful joints? Yes  No 
  12. Do you have difficulty sleeping? Yes  No 
  13. Do you experience fatigue or lack of energy? Yes  No 
  14. Do you experience cold hands or feet? Yes  No 
  15. Have you ever been advised by a physician to avoid any type of exercise? Yes  No /li>
  16. Have you ever been knocked unconscious or suffered a concussion? Yes  No 
  17. Do you (or does someone in your family) have a cardiac condition? Yes  No 
  18. Do you have any allergies? Yes  No 
  19. Are you currently taking any medications? Yes  No 
  20. Have you ever seen a Nutritionist/Registered Dietician? Yes  No 
  21. Do you smoke or have you smoked in the past? Yes  No 
  22. Do you live with a smoker? Yes  No 
  23. Do you drink coffee? Yes  No 
  24. What is your "chief complaint" (if applicable):
  25. Please state how long you have had this complaint, when you first noticed it and what you feel may have caused the problem:
  26. How does your "chief complaint" affect you on a day-to-day basis? Please state what you CAN and CANNOT do any more.
  27. Are the symptoms brought on by certain activities or positions? Yes  No 
  28. Is the pain worse at certain times of day? Yes  No 
  29. Do specific activities or positions alleviate your symptoms? Yes  No 
  30. Do you have an ergonomically set up desk/workstation? Yes  No 
  31. How many hours do you spend in front of a computer?
  32. On a scale of 1 to 10 (1=no stress, 10=a lot of stress), please rate the amount of stress in your career.
  33. 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.
  34. What is the heaviest you have weighed, and how old were you at that time?
  35. What previous treatment(s) have you tried? Please state what and when.
  36. Have you ever had any of the following: physical therapy, chiropractic, massage, acupuncture, Feldenkrais, rolfing, Alexander technique, Other? Please elaborate.
  37. What time do you usually go to bed at night and wake up in the morning?
  38. How many meals do you eat each day? List the number and time of day you usually eat these meals.
  39. How many days do you have to commit towards working out?
  40. Are there any areas of your body you want to specifically work on?

Client Signature : _____________________________ Date : ___________