Performance Stretching Intake Form - East Bank Club Page 2
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1
2Do you have any joint replacements?
Yes
No
...............................................................................................
If yes, how old are they?________________________________________________________________________________
Do you wear any type of supportive braces anywhere?
Yes
No
......................................................................
Do you wear orthotics?
Yes
No
....................................................................................................................
If yes, for how long?____________________________________________________________________________________
What percentage of your day is spent:
Sitting _____________ Standing ________________ Driving _______________
Are your symptoms worse at the end of the workday?
Yes
No
...........................................................................
Does your work station give you support and encourage good posture?
Yes
No
.............................................
How would you rate your own posture?___________________________________________________________________
MEDICAL HISTORY
Please list any recent injuries, illnesses or surgeries.__________________________________________________________
Are you currently under the care of a physician?
Yes
No
...............................................................................
If yes, please explain.___________________________________________________________________________________
List current medications, including aspirin, ibuprofen, etc.____________________________________________________
____________________________________________________________________________________________________
Please indicate whether you have had any of the following medical problems:
Cancer_________________
High/Low Blood Pressure
Digestion Problems
Ulcers
(what type)
Respiratory Problems
Cold Hands/Feet
Epilepsy
Immovable Joints
Migraines/Headaches
Sinus Problems
Heart Problems
Back Problems
Elimination Problems
Neck Problems
Bruise Easily
Sciatica
Arthritis/Bursitis
Allergies
Stroke
Immune Disorder
Fibromyalgia
Scoliosis
TMJ
Carpal Tunnel
Osteoporosis
Tendonitis
Asthma
Diabetes
Do you have any chronic or frequent pain?
Yes
No
........................................................................................
Have you had any accidents, auto or otherwise?
Yes
No
...............................................................................
Have you ever had any major surgeries?
Yes
No
...........................................................................................
Have you ever had a head injury?
Yes
No
.....................................................................................................
If yes, have you noticed any of the following:
Dizziness
Change in hearing
Change in vision
Are you pregnant?
Yes
No
............................................................................................................................
If yes, how far along are you?____________________________________________________________________________
Are there any other medical conditions we should be aware of?____________________________________________
____________________________________________________________________________________________________
The above information is accurate and true to the best of my knowledge. If there are any changes, I will inform the
Performance Stretch Therapist of my current level of health. I understand EBC does not diagnose or treat illness or
disease and does not prescribe medications. EBC has a 24-hour cancellation policy; I understand that if I cancel
within 24 hours I will be charged for the appointment unless it can be filled.
_____________________________________________________
____________________________________________
Signature
Date
04/02
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