Performance Stretching Intake Form - East Bank Club
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2EAST BANK CLUB
PERFORMANCE STRETCHING INTAKE FORM
NAME______________________________________________________________
DATE__________________________
MEMBERSHIP NUMBER______________________________ REFERRED BY____________________________________
EMAIL_____________________________________________________ PHONE__________________________________
GENERAL INFORMATION
What specific goals would you like to achieve with Performance Stretching?____________________________________
_________________________________________________________________________________________________
Are you currently experiencing any discomfort?
Yes
No
...............................................................................
How and when did the symptoms begin?_________________________________________________________________
____________________________________________________________________________________________________
How long have you had these symptoms?_______________________
Where are your symptoms located?
Please mark the areas on the figure below.
Are you currently, or have you ever been, under
medical supervision for this problem?
Yes
No
.........
Have you had any tests for this problem
(x-ray, MRI, CT scan, etc.)?
Yes
No
..........................
Describe the symptoms. Please check all that apply.
Dull
Ache
Burning
Sharp
Periodic
Constant
Sore
Stiff
Numb
Tingling
What makes it better or worse?___________________________________________________________________________
On a scale of 1 to 10, with 10 being the most severe imaginable discomfort; what is your discomfort level right now? _______
What time of day is the pain worse?______________________________________________________________________
_____________________________________________________________________________________________________
Do you have trouble sleeping?
Yes
No
.........................................................................................................
If yes, what position do you sleep in?______________________________________________________________________
PHYSICAL FACTORS
What physical activities are you currently involved in?_________________________________________________________
Do you stretch now?_____________________________________________________________________________________
Do you feel flexibility is an important part of fitness?
Yes
No
........................................................................
Have you experienced any kind of bodywork before (massage, acupuncture, etc.)?
Yes
No
...........................
If yes, what type?________________________________________________________________________________________
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