Health History Form

Please complete and submit this form at least 48 hours prior to our first session. For any boxes where you check YES, please elaborate in the box at the bottom of the page.

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Have you had a heart attack, stroke, heart surgery or chest pain? (required)
Has your doctor said you have cardiovascular, pulmonary, metabolic or other significant disease?(required)
Has you doctor said you have high blood pressure (>140/90)?(required)
Do you experience dizziness or fainting spells with activity?(required)
Are you currently pregnant or within six weeks postpartum?
Are you currently taking medication for an underlying disorder?(required)
Do you have an acute or chronic orthopedic health condition that your doctor thinks would affect your work with me, like bursitis, tendonitis, arthritis, disc bulge, fractures, neck or back pain?(required)
Do you have a medical condition not listed here that would affect your work with me?(required)
If you are a female, do you still menstruate?(required)
Are you physically inactive?(required)

After you submit this form, a copy of what you submitted will come onto the screen.

Click HERE to return to the Movement Paperwork page.