Intake FormMovement Craft Health Screening: Information & AssessmentThank you for taking the time to help me better serve your health and fitness needs. Name * First Name Last Name Email * Cell Phone Number * (###) ### #### Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Height * Weight * Date Of Birth * On a Scale of 1-10, how would you rate your current overall health and wellness? * 1 being the lowest and 10 being the highest. What specific health and wellness goals do you want to achieve? * Is there an area in your body where you are currently experiencing pain, discomfort, or have an orthopedic limitation? * Do you have any past injuries, diseases, illnesses, surgeries, and or any other conditions I should know about? * Have you been given an official diagnosis of the spine or have a spinal problem that I should know about? (i.e. spondylolisthesis, stenosis, herniated disc, osteoporosis, etc..) * Please check any body positions below that you already know you need to avoid. * Sitting on a Mat with your legs out in front of you Kneeling Lying on your side Lying on your stomach None Other (Please specify below) Can you get up and down from the floor ok? * Yes No Please list any medications you are currently taking. * Have you ever participated in strength training, Pilates, or any form of yoga? * Yes No Please share your complete movement history, including past and present physical activities, sports, and childhood activities, along with details on your current exercise regimen, if any. * How often do you travel, and what activities do you enjoy? * Please describe your Physical health in terms of your sleep and eating habits? Anything else? * Please provide a description of your Emotional and Mental health, as well as your stress level. * Do you have a spiritual practice/faith and do you desire to grow spiritually? * Please describe your current activities, including work, volunteering, business activities, retirement, or any other pursuits. * What types of Practitioners are you currently seeing? * How many hours per week can you dedicate to your health and well-being? * Is there anything else you’d like to share that would be important to know about you? * Thank you!
