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 feel free to mention any stress that you are experiencing prior to treatment or during.

All information is completely confidential.

Personal information





Health history
List in order of most important to least important and pain or dysfunction you feel is present in your body:
General health


Do you wake up feeling refreshed?
Do you have difficulty falling asleep?
Do you have insomnia?
Do you have depression or anxiety?
Do you extreme stress or pressure (general, work, life) from day to day?
Do you wake up at night to go to the bathroom?
Can you fall back asleep easily?
Do you smoke presently?
Have you ever smoked?
Do you drink alcohol?
Do you drink coffee?
Do you drink soda?
Are you a vegetarian?
Do you eat animal proteins?
Do you exercise regularly?
Have you ever seen a nutritionist?
Do you take any vitamin or supplemental products?
Have you been diagnosed with cancer?
Check the type(s) of surgeries you have had:
Have you ever been hospitalized?
Have you ever been in a car accident?
Have you ever broken any bones?
Have you ever had a sprain or dislocation?
Do you have any large scars?
Have you had excessive hair loss?
Have you been experiencing sudden tiredness or weakness?
Have you been experiencing a fever or chills?
Do you sweat easily or excessively for unknown reasons?
Musculo-skeletal system
Check all that apply:
Nervous system
Check all that apply:
Nose and sinuses
Check all that apply:
Mouth, throat, neck
Check all that apply:
Respiratory system
Check all that apply:
Cardiovascular system and peripheral vascular system
Check all that apply:
Gastrointestinal system
Check all that apply:
Reproductive system
Check all that apply:
Additional information

If necessary, I allow Monique Claudio to discuss with my health care provider the appropriateness of movement training for my general health and wellness and I understand that movement training is not a replacement for medical treatment or medical diagnosis. I release Monique Claudio from any kind of claim or injury resulting from any act or omission during movement practice or treatment. I understand that I am responsible for payment if I cancel with less than 48 hours notice.

I agree to the terms and conditions as they are stated above.

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