Health Survey

First Name

Last Name

DOB

Email address

Phone Number:Home

(Cell)

Address

City

State

Zip Code

Which of the above symptoms are the worst? (number 1-23) How long have you had them?

What treatments have you tried?

How does this affect your behavior? (check all that apply)

Moody/Irritable

Interrupts sleep

Restricts daily activities

Other

How does this affect your work? (check all that apply)

Decision Making

Exhausted at end of day

Decreased productivity

Poor atittude

Unable to work long hours

Other

How does this affect your home life? (check all that apply)

Lose patience with spouse/children

Hinders ability to exercise or participate in sports

Restricted household duties

Interfers in abilities to participate in hobbies/other desires activities

Vitality Health Center can help you with these problems. Would you like more information about these services we offer: (check all that apply)

Acupuncture/Chinese herbs

Chiropractic

Massage Therapy

Nutritional Counseling

Physical Therapy

Private Instructor Pilates

Vitality Health Center is an In-Network Provider with most PPO insurance plans. Would you like us to see if your plan's benefits would cover our services? (check all that apply)

Yes

Do you exercise regularly or participate in any sports? (if yes what kind)

Have you ever had surgery? (if yes, please describe)

Do you wear contact lenses? (yes or no)

Do you wear dentures? (yes or no)

Do you have any skin problems? (If yes, please describe)

Do you have any allergies? (If yes, please describe)

Do you take any prescribed medications? (If yes, please describe)

Have you suffered an acute injury in the past year? (If yes, please describe)

Do you have any spinal problems? (If yes, please describe)

Are you pregnant? (If yes, in which trimester are you currently)

Do any of the following apply? (Check all that apply)

Varicose veins

Athritis

Blood Clots

Heart Problems

Blood Pressure Problems

Cancer

HIV+/AIDs

Do you have any areas that require special attention?

Do you have any other medical conditions that we should be aware of before this activity?

I understand that the therapist/instructor does not diagnose illness, disease, or any other physical or mental disorder. As such, the therapist/instructor does not prescribe medical treatment or pharmaceuticals, nor does s/he perform any spinal manipulations. I also understand that this activity is not a substitute for medical examinations and/or diagnosis and that it is recommended that I see a physician for any physical ailment that I might have.

My participation in this activity is voluntary and at my own risk. To the best of my knowledge, the health information above is true and accurate. I hereby release respective owners, instructors, and therapists for any liability for any claims, demands, injuries, services, equipment or facilities provided by the therapist. I have carefully read with a full, definite, and clear understanding of the forgoing provisions and freely enter into within agreement of waiver/release.

Sign name below (First, middle initial and last)

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