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 “fragrancy 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 $60
    1st Evaluation and treatment (90-minute) Session $180.00
    thereafter
    Single (60-minutes) $120
    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 session in full. Venmo, Paypay, 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: