General Assessment Form

    Date: * / / 2013
    First Name: *
    Last Name: *
    Mobile #: *
    Home #: *
    Email Address: *
    Mailing Address: *
    Date of Birth: * / /
    Age: *
    Emergency Contact - Name: *
    Phone Number: *
    Relationship: *
    Referred By:
    Number of Hours Worked in a Week:
    Do You Enjoy Your Work? YesNoSometimes
    Rate Your Activity Level At Work:
    1 is sedentary and 10 is heavy manual labour
    How many hours do you sleep in a night?
    Do you feel rested in the morning? YesNo
    Do you have difficulty falling asleep? YesNo
    Do you have difficulty staying asleep? YesNo
    Are your bowel movements regular? YesNo
    Please specify dietary restrictions, if any:
    Are you physically active? YesNoSometimes
    Current medications or supplements:
    Family history of chronic disease:
    Special notes or medical alerts:
    What other healthcare services are you currently using:
    When was your last medical check up:
    Please indicate by checking all the numbers corresponding with where you feel pain: *
    How would you describe the pain: * burnachesharpdullradiatepulsesuperficialdeep
    Please rate the pain on a scale of 1 very mild- 10 extremely severe: * 12345678910
    Please list current and past injuries.
    Include date of injury and surgery if applicable: *
    Please list your goals:
    Please check all past and current participation in sports:
    Have you worked with a trainer before: yesno
    Was it effective: yesno
    Do you have a gym membership: yesno
    Will you be working out at home: yesno
    Please list the equipment you have:

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