Health History/Movement Readiness

HEALTH HISTORY AND MOVEMENT READINESS

Before we begin,

Your health history helps me understand your current health, previous experiences, and anything that may affect how we approach movement and coaching together.

Please answer each question as accurately as you can. You do not need to know whether something is relevant. If you're unsure, include it and we'll discuss it.

This form is not used to diagnose or treat medical conditions. If something falls outside the scope of neuromuscular coaching, I may recommend that you speak with an appropriate healthcare professional before or during our work together.

General Health

If yes, please share who you're working with and what you're currently addressing.

Have you been diagnosed with any medications that may affect your ability to exercise or move safely?

Have you had any surgeries or medical procedures?

Yes

If yes, please list the procedure and approximate date.

Injuries & Physical History

Have you experienced any significant injuries?

Yes

If yes, please describe what happened, when it occurred, and whether you're currently experiencing any effects from it.

Have you experienced recurring or persistent pain or discomfort?

Yes

If yes, where? How long have you experienced it?

Has it been evaluated by a healthcare professional? What have you been told about it?

Are there any movements, exercises, or activities you've been advised to avoid or modify?

Current Symptoms & Sensations

Please describe anything you checked. Do any of these concern you?

Pregnancy & Postpartum

Are you currently:

Pregnant

Postpartum

Neither

How many weeks pregnant?

Has your pregnancy care provider given you any restrictions, precautions, or recommendations regarding physical activity?

Yes

If yes, please describe.

When did you give birth?

What type of birth did you have?

Vaginal

Cesarean

Assisted vaginal birth

Other

Have you been cleared by your healthcare provider for the level of physical activity you're seeking to do?

Yes

I'm unsure

Are you currently experiencing anything related to pregnancy, childbirth, or postpartum recovery that you're concerned about?

Exercise & Movement

What does your current exercise or movement routine look like?

How many days a week are you typically active?

What types pf exercise or movement do you currently do?

Are there any movements or exercises you currently avoid? Why?

Previous Approaches

What approaches have you tried? Did they help? If yes, what helped? What didn't?

Is there anything you specifically do NOT want to repeat in your coaching experience?

Movement Readiness & Communication

Is there anything that makes movement or exercise feel unsafe, uncomfortable, or difficult for you?

Is there anything I can do to make our sessions more comfortable or accessible for you?

Is there anything about your health or physical history that you think I would know before we begin?

Important

Please understand that neuromuscular coaching is not medical care and does not replace evaluation, diagnosis, or treatment from a qualified healthcare professional.

If you develop a new, severe, unusual, or concerning symptom, seek medical care rather than relying on coaching.

If your health status changes during our time together, please let me know so we can determine whether your coaching needs to be modified or whether additional professional guidance is appropriate.

Client Acknowledgement

I confirm that the information I have provided is accurate to the best of my knowledge. I understand that it is my responsibility to communicate changes in my health.

Signature

Drawing mode selected. Drawing requires a mouse or touchpad. For keyboard accessibility, select Type or Upload.