Please fill in the below:

Client Information:


* Required fields

*Receipt Number:
*Name:
*Address:
*City:
*Postal Code:
*Home Phone:
Work Phone:
Occupation:
Email:
Skype ID:
Height:
Weight:
*Age:
*Date of Birth:
*Sex:
Physician's Name:
Physician's Phone:
*Emergency Contact Person:
*Emergency Contact Phone - House:
*Emergency Contact Phone - Work:



Preliminary Consultation Questions:


Have you watch all of the videos and read the two manuals in the Fix My Shoulder Pain system and have an understand of it?

YesNo

Based on the self-assessment, have you followed the recommendations for 7 straight days?

YesNo

Are you willing to invest 10 to 20 minutes on a daily basis to overcome your shoulder pain?

YesNo



Shoulder Information:


Background on Your Shoulder Injury or Pain
Provide a background of your injury (4 to 5 sentences)

Shoulder Assessment
Provide a summary of your shoulder self-assessment. If you would like, you can send a quick video assessment via http://sendspace.com to the email address [email protected]

What Things Make Your Shoulder Pain Worse?

What Things Make Your Shoulder Pain Better?

What Has Helped in the Past for Your Shoulder Pain?

What Have You Tried in the Past?

Is There Anything Else You Would Like to Add:



Medical History:


Physical Activity should not pose a problem or hazard for most people, however, this questionnaire is designed to identify the small number of people for whom physical activity may be inappropriate, or who may need medical clearance concerning the type or intensity level of physical activity most suitable for them.

1. Has your doctor ever said that you have heart trouble? YesNo

2. Do you frequently have pains in your heart and chest? YesNo

3. Do you often feel faint or have spells of severe dizziness? YesNo

4. Have you ever had a stroke? YesNo

5. Has your doctor ever told you that you have a bone or joint problem such as Arthritis that has been aggravated by exercise or might be made worse with exercise? YesNo

If Arthritis, please state type of Arthritis Type:

6. Has your doctor ever said your blood pressure was too high? YesNo

7. Has your doctor ever said your blood pressure was too low? YesNo

8. Do you have a history of breathing or lung problems? YesNo

9. Do you have diabetes or a thyroid condition? YesNo

10. Are you pregnant or have you been within the last 3 months? YesNo

11. Have you received rehabilitation services for any injuries and/or accidents? YesNo
If yes, please list

12. Have you experienced any serious injuries or undergone surgery in the past year? YesNo
If yes, please list

13. Have you experienced muscle, joint or back pain that may be aggravated by a change in your level of physical activity? YesNo

14. Do you smoke cigarettes? YesNo

15. Have you ever had a near drowning experience? YesNo

16. Has your doctor ever said that you have an elevated level of blood cholesterol? YesNo

17. Are you currently taking any prescribed medication? YesNo
If yes, please list

18. Do you have any allergies that we should be aware of? YesNo
If yes, please list

19. Do you know of any other reason why you should not be physically active? YesNo
If yes, please list

Please use the space provided below to address any of the questions to which you answered “yes”, or to address any concerns you may have:



WAIVER FOR PARTICIPATION:


I have read, understood, and completed this questionnaire. Any questions I had were answered to my full satisfaction. I, the undersigned, parent or guardian (if under 18), do hereby agree to allow the individual(s) named herein to participate in the aforementioned activity(s). Further, my family and I agree to indemnify and hold Rick Kaselj and Healing Through Movement harmless from and against any and all liability for any injury, including death, which may be suffered by the aforementioned individual(s), arising out of or in any way connected with his/her participating in this/these activity(s).

By clicking on the Send button below, you are signing this waiver freely and voluntarily.