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    Member First Name:

    Member Last Name:

    Age:

    Cell Phone:

    DOCTOR WHO BEST KNOWS YOUR HISTORY

    Doctors Name:

    Doctors Phone:

    Please complete all entries
    to best customize your program

    MEDICAL

    Walking Assistance?
    NoneCaneWalkerOther

    Medical Conditions

    Arthritis:
    YesNo

    Cancer:
    YesNo

    Diabetes:
    YesNo

    Heart Attack:
    YesNo

    If Yes, what year?

    Stroke:
    YesNo

    If Yes, what year?

    Unstable Blood Pressure:
    YesNo

    Medical Conditions

    Osteoporosis:
    YesNo

    Dizziness/Vertigo:
    YesNo

    Fractures

    Hip:
    YesNo

    Yes, what year?

    Knee:
    YesNo

    If Yes, what year?

    Ankle/Foot:
    YesNo

    If Yes, what year?

    Pelvis:
    YesNo

    If Yes, what year?

    Shoulder:
    YesNo

    If Yes, what year?

    Spine:
    YesNo

    If Yes, what year?

    SURGERIES

    Cardiac Surgery

    Heart Bypass:
    YesNo

    Yes, what year?

    Pacemaker:
    YesNo

    If Yes, what year?

    Defibrillator:
    YesNo

    If Yes, what year?

    Valve:
    YesNo

    If Yes, what year?

    Stents:
    YesNo

    If Yes, what year?

    Total Joint /Other Surgery:

    Left Shoulder:
    YesNo

    Yes, what year?

    Right Shoulder:
    YesNo

    If Yes, what year?

    Left Hip:
    YesNo

    If Yes, what year?

    Right Hip:
    YesNo

    If Yes, what year?

    Left Knee:
    YesNo

    If Yes, what year?

    Right Knee:
    YesNo

    If Yes, what year?

    Total Joint /Other Surgery:

    Left Ankle/Foot:
    YesNo

    Yes, what year?

    Right Ankle/Foot:
    YesNo

    If Yes, what year?

    Neck Surgery:

    Disk:
    YesNo

    Yes, what year?

    Stenosis:
    YesNo

    If Yes, what year?

    Spine Fusion:
    YesNo

    If Yes, what year?

    Back Surgery:

    Disk:
    YesNo

    Yes, what year?

    Stenosis:
    YesNo

    If Yes, what year?

    Spine Fusion:
    YesNo

    If Yes, what year?

    Other

    Enter more info as needed

    OTHER SYMPTOMS

    Energy:
    ExcellentGoodFairLow

    Swelling feet/legs:
    NoneSometimesDaily

    Numbness/tingling/ burning feet:
    NoneSometimesDaily

    Shortness of breath:
    YesNo

    Lying down:
    YesNo

    Stairs:
    YesNo

    Walking Fast:
    YesNo

    Other

    Enter more info as needed

    VISION

    Normal Vision:
    YesNo

    Glaucoma:
    YesNo

    Macular Degeneration:
    YesNo

    Other

    Enter more info as needed

    FALL HISTORY

    Any falls?:
    ExcellentYesNo

    If Yes, # in the past year:

    Dizziness/Vertigo:
    YesNo

    Loss of Balance:
    YesNo

    Leg Buckled:
    YesNo

    Environment:
    YesNo

    Unknown:
    YesNo

    Other

    Enter more info as needed

    PHYSICAL ACTIVITY

    What is your activity level?

    Select:
    ActiveNone

    Activity Type: Enter # of times per week

    Walking:

    Bike Indoor:

    Bike Outdoor:

    Calisthetics:

    Free Weights:

    Treadmill:

    Jog:

    Tennis:

    Golf:

    Eliptical:

    Weight Machines:

    Other

    Enter more info as needed

    Other- Enter activity type & number of times per week: