If you are a new client or your health conditions have changed over the last 6 months, please send Susan your health information below.

If you are unable to complete this form online, please download and print the PDF form below. Sign, date, and bring to your first session or contact Susan to receive a copy by mail.

Client Health Conditions (download .PDF form here)


I am*: a New Client updating health conditions

       
Cardiovascular YES NO COMMENTS
Hypertension
Hypercholesterolemia
Heart Murmurs
Heart Attack
Fainting/Dizziness
Chest Pain
Palpitations
 
Pulmonary YES NO COMMENTS
Asthma
Exercise-induced Asthma
Bronchitis
Emphysema
Breathlessness
Difficulty Breathing During Mild Exertion
 
Metabolic YES NO COMMENTS
Diabetes
Obesity
Hypoglycemia
 
Musculoskeletal YES NO COMMENTS
Osteoporosis
Osteoarthritis
Low Back Pain
Prosthesis
Muscular Atrophy
Swollen Joints
Orthopedic Pain
Artificial Joints
Limping/Lameness
 
Risk Factors† YES NO COMMENTS
Male Older Than 45 Years of Age
Female Older Than 55 Years of Age
Hysterectomy
Smoking or Quit Smoking In Past 6 mos.
High Blood Pressure
Don't Know Blood Pressure
Taking Blood Pressure Medication
High Cholesterol
Don't Know Cholesterol Level
Overweight by More Than 20lbs. (9kg)
Physically Inactive
 
†If you have two (2) or more risk factors, please consult your physician before engaging in exercise.
 
Additional Health Information
Please describe any conditions, syndromes, surgeries, or injuries that are not included on the Checklist for Signs and Symptoms of Disease. Please also state if you currently under the care of a physician or therapist for a particular condition, injury, etc. that you feel I need to be made aware of.

Today's Date: May 20, 2012

Client Name*:     Email*:

* Required fields.


site design : effie