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MOVE Health History Form
Please fill this out to the best of your ability and as thoroughly as possible, PRIOR to your assessment. This information is required and helps us tremendously! Thanks in advance! If you have any questions, email
info@movementovereverything.com
.
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Email
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Your email
Full Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Height (inches)
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Your answer
Weight (pounds)
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Your answer
City, State
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Your answer
Has a physician ever told you for any reason not to exercise?
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Yes
No
If Yes, Why?
Your answer
Please list any prescription medications you currently are on, and why.
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Your answer
Have you ever experienced chest pain, heart attach, stroke, bronchitis, vascular disease, diabetes, asthma, etc? If so, please explain.
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Your answer
Do you suffer from ankle swelling, heart palpitations, shortness of breath, rapid heartbeat, or dizziness? If so, please explain.
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Your answer
Do you have any family history of heart attack, coronary revascularization, sudden death in immediate relatives? (Father, Brother, Son under 55, Moth, Sister, Daughter under 65?). If so, please explain.
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Your answer
Do you have high blood pressure? If yes, please list. If no, and you are aware of it, please list.
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Your answer
Do you have impaired fasting glucose levels (Greater than 100mg/dl on two or more occasions)?
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Yes
No
Maybe
Do you have hypercholesterolemia? (Total cholesterol greater than 200mg/dl, OR LDL greater than 130mg/dl, OR HDL below 35mg/dl) If yes, please list.
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Your answer
Do you lead a sedentary lifestyle?
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Yes
No
Maybe
Do you smoke? If yes, please explain.
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Your answer
Do you have any neck, back, knee, hip, shoulder, or other musculoskeletal problems? If yes, please explain.
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Your answer
What has your previous exercise experience been before Movement Over Everything? Please be thorough.
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Your answer
Do you have any pain with any movements? If so, explain.
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Your answer
What are some things you liked?
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Your answer
What are some things you disliked?
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Your answer
Are there any certain activities you'd like to avoid?
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Your answer
Please discuss your goals below. Please be as detailed as possible. What would you like to get out of working with Movement Over Everything?
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Your answer
CONTINUE ONLY IF ALSO INTERESTED IN NUTRITION SERVICES
What are your nutrition goals?
Your answer
What are your nutrition challenges?
Your answer
What would you like to gain from working with a dietician?
Your answer
If you've received dietary counseling in the past, how long ago and for what reason?
Your answer
Are you currently taking any supplements? If so, please list what and why.
Your answer
How many alcoholic beverages per week?
Your answer
How many times per week do you dine out or get takeout?
Your answer
How many hours of sleep do you get on average?
Your answer
Do you tend to skip meals? If so, Why?
Your answer
Have you made any recent changes in your diet? If so, Please Describe.
Your answer
Please Describe your dieting history.
Your answer
Please list any food allergies or intolerances.
Your answer
Please List any details regarding weight history (highest and lowest adult weight).
Your answer
Social History
Living Situation
Live Alone Single
Live Alone Divorced
Live Alone Widowed
Live with Spouse
Live with Partner
Live with Children
Live with Roommates
Live with Parents
In your household, who cooks?
Your answer
Who shops?
Your answer
Occupation:
Your answer
Average daily work hours:
Your answer
How often do you travel for work/pleasure?
Your answer
How would you rate your stress level?
Low
1
2
3
4
5
High
Clear selection
What do you do to manage stress?
Your answer
What did you eat yesterday? Please list breakfast, any snacks, lunch, any snacks, dinner and any additional snacks. If possible, also list any liquids consumed.
Your answer
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