Client Intake Form Client Intake Form Date * Instructor Performing Intake Client Name * Gender Female Male Prefers not to say Have you ever been treated for: heart disease high blood pressure gastric reflux orthopedic/joint (shoulder/elbow/spine/hip/knee) problems osteoporosis arthritis peripheral neuropathy (numbness/tingling/diminished sensation) i have never been treated for any of these issues Are you Pregnant Yes No Prior Deliveries? Prior Surgeries? (please list "N/A" if none.) Prior Injuries? (please list "N/A" if none.) Client information (history of exercise, injuries, surgeries, etc.) & (your) Postural Evaluation Notes Client’s Goals (in their words) GENERAL MOVEMENT PATTERNS Standing Alignment- (pelvis, knees, feet, ribs, shoulders, head) Lift arms out & up (shoulders?, restrictions?) Breathing (Pump, Costal, Diaphragm)_ Single Leg Stance - start feet together (Balance? Watch if foot rolls in (Pronation) or rolls out (Supination). Does Pelvis Tuck?) Squat - (Look at hips, knees, feet) Toes - Can they move them -Proprioception test Heel Raises - Can they do without holding on, Ankles? Hip Extension - extend 1 leg behind - does lumbar go with it? Hip Extension - extend 1 leg behind - does lumbar go with it? SPINAL MOVEMENT PATTERNS Cervical Movement (turn R/L, Tilt R/L, Flexion, Extension)_ Lumber movement (Flexion/ Extension) Neutral, Posterior or Anterior tuck? Hip Hinge Full Spinal Flexion - Roll Down Spinal Extension (tilt backward) Thoracic Awareness - Kyphosis-from computer work or excessive? Forward Head Posture? Trunk-Thoracic Rotation - any lateral deviation? Trunk Side Bending STABILITY Hands & Knees - can they even support themselves. Where do they place arms & legs? Lumbar? Lumbopelvic Stability - Marching CLIENT & INSTRUCTOR GOALS (ordered by priority): 1 2 3 FREQUENCY OF SESSIONS & HW: If Client’s goal is to take Reformer classes - they must be aware of/ able to do the following: Change Springs Adjust Footbar Adjust Head rest Get their own feet in straps Short Box/ Long Box Orientation and placement Footwork Supine Arm Work Feet in straps (understanding pelvic placement) If you are human, leave this field blank.