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HEALTH ASSESSMENT


Personal Information
Name *
Name
Birth Date *
Birth Date
Address *
Address
Phone *
Phone
Emergency Contact Name *
Emergency Contact Name
Emergency Contact Phone *
Emergency Contact Phone
Physician's Name *
Physician's Name
Physician's Phone
Physician's Phone
Physical Activity Readiness
Personal Health History
Last Physical Exam *
Last Physical Exam
Women's Health
Injuries
Please check any of the following injuries you have had and specify which bone, muscle, joint, etc. *
Cardiovascular
Please check any that apply and indicate the age of onset:
DIet and Nutrition
What diet plans have you tried? *
Lifestyle
How would you describe your current stress level? *
Exercise Habits
Pain Assessment
If YES, please specify and indicate all areas on the anatomy chart where you feel numbness, pain, tingling, achey or spasms: *
Fitness Goals
Interests
Please indicate any activities which are of interest: *
Readiness
Do you feel more strongly that: (choose one) *
What is a higher priority for you at this moment in time: (choose one) *