Audit

Medical Information
Please answer all questions from the responses received from your client if yes then ask for details and record:

Do you suffer from back pain ? If yes please explain?

Are you sensitive to touch/pressure in any area ? If yes please explain?

Do you have tension or soreness in any specific area? If yes please explain?

Do you have numbness or stabbing pains anywhere?

Do you have numbness or stabbing pains anywhere?

Are You pregnant?

Do you have high blood pressure?

Do you have high cholesterol?

Are you epileptic?

Have you ever had surgery or medical procedure?

Have you ever broken any bones?

Do you experience stiff, swollen or painful joints?

Do you have difficulty sleeping?

Do you experience fatigue or lack of energy?

Do you experience cold hands or feet?

Have you ever been told by a Doctor to avoid any type of exercise?

Have you ever been knocked unconscious or suffered concussion?
If yes, please state how, how many times and the dates?

Do you (or someone in your family) have a cardiac condition?

Do you have any allergies?

Have you ever seen a Nutritionist/Registered Dietician?

Do you smoke?

Have you smoked in the past?

Do you live with a smoker?

Do you have any current injuries?

Upper Limb:
Any pins and needles or numbness?

Upper Limb:
Do you get any strong pain while doing everyday simple tasks (Not sport)?

Upper Limb:
Do you ever feel your shoulder give a big "clunk" or "pop out of it's socket?

Upper Limb:
Do you suddenly ever loose strength in your arm for no reason, with or without pain?

Lower Limb:
Any pins and needles or numbness or strange weakness in your leg?

Lower Limb:
Do you get any strong pain while doing everyday simple tasks (Not sport)?

Lower Limb:
Do your leg ever give way or feel unstable for any reason?

Lower Limb:
Has your problem spread to other parts of your body?

Spine:
Any pins and needles or numbness or strange weakness anywhere in the limbs, around the face of pelvis?

Spine:
Have you had within the last six weeks, or do you currently get, any strong pain in your spine (or headaches)?

Spine:
Do you get any pain with coughing or breathing deeply?

Spine:
Have you had pain in your spine for mare than six months, despite exercising weekly?

Do you have any current injuries?

What are your injuries ?

When is the pain the worst?

What previous treatment(s) have you had/tried?

Are you taking any medication? If so what are you taking?

Have you ever had any of the following - physical therapy, chiropractic, massage, acupuncture, Other?

Do you drink coffee? How many cups per day ?

How many hours do you spend in front of a computer?

Do you have an ergonomically set up desk/work station?

What time do you go to bed at night?

What time do you get up in the morning?

How much time do you spend in the seated position in a day?

How many meals do you eat each day? List the number and time of the day usually eaten.

On a scale of 1 to 10 (1=No stress, 10=a lot of stress), please rate the amount of stress in your career.
On a scale of 1 to 10 (1=No stress, 10=a lot of stress), please rate the amount of stress in your personal life?

How many days do you have to commit towards working out?

Is there any area of your body that you want to specifically work on?

BP, Weight, Height and BMI.

Details:

Measurements:
Biceps, Chest, Waist, Hips, Thighs and Calves.

Details:

NOTES:

Clients Signature:
Clients Photo
Assessors Signature:
Date and time of Assessment
Please note that this checklist is a hypothetical example and provides basic information only. It is not intended to take the place of, among other things, workplace, health and safety advice; medical advice, diagnosis, or treatment; or other applicable laws. You should also seek your own professional advice to determine if the use of such checklist is permissible in your workplace or jurisdiction.