Client Question Form - Performance Training Center

Q.No

Question

Age

Tell me about your chief complaint(s) why are you here?

Do you take prescription drugs, including birth control pills? Yes No

Have you ever used prescription drugs at any time in the past, i.e., antibiotics during childhood? Yes No

Do you smoke? Have you ever smoked? Do you currently or have you ever lived with someone who smoked, even as a child?

Do you consume alcoholic beverages? If so, how much? What was your frequency of alcoholic beverage intake at any time in the past?

Do you have any history of physical trauma or surgeries? Have you ever had your tonsils, appendix, or gall bladder removed?

Do you consider yourself overweight, underweight, or ideal weight?

Do you live in an urban or rural area?

Is your water source filtered, clean? Yes No

Who do you live with?

How many hours do you sleep at night? Do you have trouble falling asleep? Do you wake up in the middle of the night?

Do you work shifts?

Tell me about your job?

Tell me about your hobbies?

Tell me about your exercise habits now and in the past?

Do you have problems with constipation or diarrhoea? How often per day do you have bowel movements? If a problem exists, how long has it persisted?

Do you have any problems with urination relating to frequency or pain? If so, how long?

Do you have ongoing pain in any part of your body? If so, how long?

Have you ever travelled to foreign countries, including Mexico? If so, did you ever suffer from “Montezuma’s revenge” or any other GI disturbances?

How fast do you eat? What do you think about when you eat? Do you ever eat standing or “on the run?”

How much fluid do you drink when eating?

What would you desire to change and realistically achieve in regards to your health? What are your key goals?

Is there anything else I should know about you that we have not yet discussed?

Questions that can be asked to your client