Health and History Questionnaire In order for me to design a safe and effective program tailored to your interest, it is important that you complete the following Health History to the best of your ability. The information will be used for need determination, not diagnosis. Name* First Last Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Home Phone*Work PhoneCell PhoneEmail* Occupation Emergency Contact* First Last Emergency Contact Phone*Date of Birth* MM slash DD slash YYYY Height* Weight* Please describe your pertinent medical history, with dates whenever possible. Has your doctor ever told you that you have heart problems?* Yes No Has your doctor ever told you that you have high blood pressure?* Yes No Is there a history of heart disease in your immediate family?* Yes No Are you pregnant or have you given birth in the past six months?* Yes No Do you smoke?* Yes No Are you a former smoker?* Yes No Describe any illnesses or injuries:Describe any surgeries:What have physicians or practitioners provided in terms of diagnosis or treatment?Are you taking any medication or drugs? If yes, please list medications and for what condition.Describe areas of your body where you are experiencing pain, stress, fatigue, or restricted movement:What kind of activities do you perform while working or in other aspects of your life, which seem to stress certain areas of your body?What would you like to focus on in your Aston-Patterning® sessions (i.e., posture, movement, pain relief, movement efficiency, stress relief, fitness, athletic performance, etc.)?What other kind of medical care or body disciplines are you currently involved in, if any, and with whom?Is there anything else that you would like your Aston-Patterning® practitioner to know about your history, specific problems, or goals?Do you understand that Aston-Patterning® / Aston Kinetics® is not a medical procedure and is not a substitute for medical diagnosis?* Yes No By submitting this form you certify that the above information is true and accurate to the best of your knowledge and you give permission to proceed with an Aston-Patterning® session(s). Name* Use your mouse or finger to sign below.*
