StudioKatieG

Client Questionnaire

Please complete and submit this questionnaire before scheduling your first appointment.

You are welcome to contact me at katie@studiokatieg.com
if you wish to share more detailed information.
 

Name *
Name
(Add preferred nickname in parentheses)
Specify Skype, Zoom or FaceTime and include contact address or number
Specify Skype, Zoom or FaceTime and include contact addresses or numbers
List and date any injury, illness, surgery or trauma (regardless of how long ago these occurred) that currently affect your mobility, pain level or ability to engage in physical activity.
Please describe your current physical condition, including any strengths and weaknesses, chronic postural or movement patterns, and recent changes.
Please describe your current movement and exercise regimen, frequency, duration, intensity, etc.
Movement & Exercise Goals *
Please check all that apply
You may use this space to write in more detail about any goals and intentions you have for our work together.
Obstacles to Movement *
Select any of these that apply
You may use this this space to write in more detail about any obstacles to movement that you are experiencing.
Please explain:
If yes, please explain:
If yes, please explain:
Do you have a history of any of the following? *
If so, what is your smoking frequency? Would you like to quit?