Client Intake Survey for MyoTopia

Name
First Last
Are you currently taking any supplements?*
While I am not qualified to direct you about the amount or variety of supplements that you take, knowing how you are supporting your body is critical to designing an appropriate exercise program.
- Yes
- No
Supplements
Please list all supplements that you are currently taking. Click "+" at the end of the row to add another supplement.
Name of Supplement Dosage (if you don't know, that is ok for now) Why and for how long have you been taking this supplement?
Do you currently smoke?*
- Yes
- No
How much do you smoke and for how long have you been smoking?*

Diagnosed Conditions
Please check if you have been diagnosed with conditions in these categories:
- Orthopedic (arthritis, hypermobility, frozen shoulder, etc.)
- Metabolic (Diabetes, Hypothyroid, etc.)
- Neurological (Stroke, Parkinson's, etc.)
- Dental work (braces, bite plates, appliances, etc.)
Please give more details about your orthopedic diagnosis.*
Please give more details about your metabolic diagnosis.*
Please give more details about your neurological diagnosis.*
Please give more details about your Dental work.*

Goals, Expectations, and Preferences
What are your fitness/wellness goals? Please be as specific and inclusive as possible.*
Are you making progress towards your goals currently? Is there anything that is working for you? Is there anything that is NOT working for you?

What physical activities and/or physical positions can you not perform (I.e. kneeling down, reaching overhead)?
What self-care strategies do you currently use to manage your own health and why (Ice packs, stretching, acupuncture, magnets, heating pad, massage, etc.)?

What lets you know that you are having a good workout?
What lets you know that your workout was not good?
What are your favorite activities?
Are there any of these activities that you can not currently do? Why not and for how long have you been unable to participate?
Do you see yourself participating in your favorite activities for the rest of your life? If not, how much longer would be acceptable, i.e. when do you plan to stop participating?

What is your idea of a good adventure?
What prevents you from going on adventures?
Are there any activities or exercises that you do not like?
Did you know that when you are training your body, you are also training your mind? What does this mean to you?
Are there any other physical issues that you have noticed that just won't go away?

Injuries, sprains, and strains

Name of Supplement	Dosage (if you don't know, that is ok for now)	Why and for how long have you been taking this supplement?