Health & Exercise History Questionnaire

Date of first visit:
Name:

Address:

Contact Number(s):

E-mail address:

DOB:

Age:

Marital Status:

Number of Children:

Age of children:

Occupation:

Handedness:

General Health History:

List in order of most important to least important and pain or dysfunction you feel is present in your body, and Date of dysfunction:
1.
2.
3.
Date of onset of dysfunction
Number of symptoms or painful issues currently
Have you seen a general practitioner or specialist for any of these problems? YesNo
Was there any treatment or diagnosis given?
Has the condition changed with treatment?

General Health

Current Weight
Current Height
Have you recently had any rapid weight gain or loss? YesNo
General energy level (scale of 1-10, 10 being optimal)
Average hours of sleep per night:
Do you wake up feeling refreshed? YesNo
Do you have difficulty falling asleep? YesNo
Do you have insomnia? YesNo
Have Depression or Anxiety? YesNo
Do you feel extreme stress or pressure (general life, work) from day to day? YesNo
Do you wake up at night to go to the bathroom? YesNo
Can you fall back asleep easily? YesNo
Number of times you wake up during an average night:
If you wake during the night, at what time or times do you awaken in the night?
Do you smoke presently? YesNo
How long have you smoked?
Have you ever smoked? YesNo
Do you drink alcohol? YesNo
How often?
Do you drink coffee? YesNo
How much per day?
Do you drink soda? YesNo
How much per day?
How much water do you drink per day?
Are you a vegetarian? YesNo
How long?
Do you eat animal proteins? YesNo
How many meals do you eat per day on average?
Do you exercise regularly? YesNo
Types of exercise:
Have you ever seen a nutritionist? YesNo
Do you take any vitamin or supplemental products? YesNo
Have you been diagnosed with cancer? YesNo
Type:
Have you ever had any surgeries? YesNo
Please select all that apply: BoneTumorDentalCosmeticMuscularCartilageTendonOrganEyeEarImplantsTransplantsPacemakersStintsShuntsJoint replacements

Have you ever been hospitalized? YesNo
How long?
When?
Car Accidents? YesNo
Broken Bones? YesNo
Sprains or Dislocations? YesNo
Any Scars? YesNo
Have you had excessive hair loss? YesNo
Sudden tiredness/weakness? YesNo
Time of day:
Fever/chills? YesNo
Sweat easily or excessively for unknown reasons? YesNo
Musculo-skeletal System - Please check any areas that apply Low Back painMid-back painNeck painArm ProblemsLeg ProblemsJoint pain or dysfunctionMuscular pain or dysfunctionArthritisDifficulty walkingBroken bonesLeg problemsTorn musclesMuscle strainsLigament sprainsCartilage dysfunction or tearsConstant joint stiffness or ache
Nervous system Numbness/tinglingDizziness or VertigoFaintingFrequent Headaches or MigrainesFrequent Muscle Twitching, ticks or spasmsLoss of coordinationLoss of balance
Nose and Sinuses Nose PainFrequent nose bleedsDifficulty breathing through noseHay feverAllergiesFrequent sinus infectionsNose surgery or reconstruction
Mouth, Throat, Neck Frequent sore throatsGum problemsGrinding of teeth, TMJ, Clicking JawDental crowns, bridges, mouth workGland swellingBraces (current or history)
Respiratory System AsthmaChronic/frequent coughingPain on breathingFrequent shortness of breath
Cardiovascular System and Peripheral Vascular System High blood pressureHeart murmursHeart palpitationsIrregular heart beatVaricose veins
Gastrointestinal System Frequent ConstipationFrequent diarrheaAbdominal painColitis, Crohn’s Disease, or UlcersFrequent Nausea/vomitingFrequent heartburnFrequent indigestion or gasFrequent cramps
Reproductive System Prostate issues or enlargementsFibroids, cysts, or endometriosisFrequent crampingHeavy flow during periodMenopause or peri-menopausal symptomsC-sectionProlapsedIrregular cycleCurrently pregnant
If pregnant, list week:
Any additional information you would like to include:

If necessary, I allow Anne Sotelo to discuss with my health care provider the appropriateness of Manual Therapy and movement training for my general health and wellness and I understand that Manual Therapy or movement training is not a replacement for medical treatment or medical diagnosis. I release Anne Sotelo from any kind of claim or injury resulting from any act or omission during movement practice or Manual Therapy treatment. I understand that I am responsible for payment if I cancel with less than 24 hours notice.

Please use your mouse or touchscreen to sign in the area below:

Anne’s Policies:

Consultations are by appointment only. Appointments are approximately 90 minutes. Please come to the session as “fragrant free” as possible.

Please fill out all forms as fully, accurately and honestly as possible. Small details are just as important as major issues in assessing the body systems. Mental, emotional and social aspects of your life all play a role in your overall health. Please mention any stress or discomfort that you experience during the session! Manual and Melt therapy should not cause pain.

All information is completely confidential. Thank you.

Manual Therapy Fee Schedules: All Prices Below Reflect in House Sessions; Outcall add $40
1st Evaluation and treatment (90-minute) Session $150.00
thereafter
Single (60-minutes) $120
Single (75-minutes) $150
Single (90-minutes) $180

Melt Method Fee Schedules: All Prices Below Reflect Single Sessions
Initial Evaluation and Session (90-minutes) $150.00
1x/wk: 95.00 (60-minutes)
2x/wk: 85.00 (60-minutes)
3x or more/wk: 75.00 (60-minutes)

Cancellation Policy:
Please give a minimum of 24 hours notice if you are unable to keep your appointment. Otherwise you will be charged for the session in full as this time has been specifically reserved for you.

Payment:

This is due at the end of each session in full. Cash, credit cards or personal checks are acceptable.

Participant Information:

Please do not eat any food if possible one hour prior to appointment. Life-sustaining medications and remedies may be taken. Please wear comfortable active wear to your Melt Method appointments. Please wear briefs (gentlemen), underwear and camisole or non-underwire or non-sports bra (ladies) for Manual Therapy/ Rolfing appointments. Drink at least 8oz. of water prior to session as well as stay very hydrated the day after sessions. It is best not to wear a watch, belts or jewelry for sessions, as I will ask you to take off any metal during sessions
Please use your mouse or touchscreen to sign in the area below: