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BE Your Best You.
About
The Body Engineers
Our Why
BE Team
Blog
Personal Training
Group Classes
Muscle Activation Techniques
Online Coaching
Contact Us
Do you think your body is operating as efficiently as it can be?
Fill out our questionnaire and find out!
YOUR CONTACT DETAILS
Name
*
First Name
Last Name
Date of Birth
*
MM
DD
YYYY
Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Email
*
Phone
*
(###)
###
####
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone
*
Country
(###)
###
####
Do I have permission to contact your physician regarding your treatment/training program?
*
Yes
No
Does your physician know you intend on participating in treatment and/or an exercise program?
*
Yes
No
YOUR REASON FOR VISITING
What are your primary goals?
*
Please select all that applies
Reduce Pain
Recover from Injury
Avoid Injury
Lose Body Fat
Increase Muscle
Increase Strength
Reduce Stress
Improve Performance
Sport Specific Training
Enhance Longevity
Please describe, in as much detail as possible, your goals in the text box below:
*
What is your current complaint/pain (physical or emotional)?
*
What movements or activities are limited?
*
What, if anything, makes your condition worse?
*
What, if anything, makes your condition better?
*
Have you had any of these conditions in the past?
*
Yes
No
If yes, was it resolved?
YOUR OVERALL HEALTH
Are you currently taking any medications or drugs?
*
Yes
No
If yes, please list them by name and associated purpose
Do you have any history of heart problems?
*
Yes
No
Do you have any history of high blood pressure?
*
Yes
No
Do you have any history of chronic illness or conditions?
*
Yes
No
What is your occupation?
*
What are your main occupational activities?
*
Please select all that apply
On the phone
Computer work
Sitting
Walking
Driving a vehicle
Lifting/bending
Repetitive movements
Standing
Other (please state below)
Please state the number of hours per day for each in the text box below
Do you have difficulty with activities of daily living?
*
Yes
No
If yes, please explain in text box below
Do you have any surgery history (dental, cosmetic included)
*
Yes
No
If yes, please explain in text box below
Have you been pregnant?
*
Yes
No
If yes, please state how many times and describe how your pregnancies were in the text box below
Are you currently pregnant or have been in the last 6 months?
*
Yes
No
Do you have any conditions relating to having been pregnant?
*
Yes
No
If yes, please explain below
Do you have any of the following?
*
Please tick all that apply.
Lung or breathing problem
Diabetes
Smoking habits
Hernia or any condition that may be aggravated
Orthopaedic (bone/joint) issue
Muscular issue
Back disorder
No to all
If yes to any, please explain in the text box below
YOUR CURRENT ACTIVITY LEVELS
Do you do any formal exercise?
*
Lifting weights, running, etc.
Yes
No
If yes, please explain and state frequency below
Do you do any informal exercise?
*
Walking, chores, etc.
Yes
No
If yes, please state frequency in the text box below
Have you been sedentary (inactive) for the past year or more?
*
Yes
No
SLEEP
Approximately how many hours do you sleep per night on average?
*
Less than 2h
2 to 3h
3 to 4h
4 to 5h
5 to 6h
6 to 7h
7 to 8h
More than 8h
Do you wake up during the night?
*
Never
Very little
Sometimes
Often
Every night
If yes, please state the time in the text box below
Please describe your sleep quality
*
Do you have fatigue during the day?
*
Yes
No
STRESS
How would you describe the emotional climate of your home?
*
Please rate the level of stress at your work or in other aspects of your life
*
1 = very good, 10 = very bad
1
2
3
4
5
6
7
8
9
10
Please describe the nature of your stress
*
NUTRITION
Please rate your diet on a scale of 1 to 10
*
1 = very unhealthy, 10 = very healthy
1
2
3
4
5
6
7
8
9
10
Describe what needs the most improvement in your diet
*
Approximately how much water do you drink per day (in litres)?
*
CURRENT AND PREVIOUS HEALTH CARE
Are you currently using other health care methods?
*
Physiotherapy
Reflexology
Chiropractic
Osteopathy
Massage
Psychotherapy
Acupuncture
Massage
Other
No
If Other, please state below:
Have you had a Muscle Activation Techniques (MAT) session before?
*
Yes
No
If yes, please state the practitioner you saw, the approximate date of your last session and frequency of visits
EXPECTATIONS AND COMMITMENT
What are your expectations when working with the Body Engineers?
*
How much time are you willing to commit to your recovery/exercise program?
*
Please state minutes per day and days per week below.
WAIVER AND RELEASE OF LIABILITY
By Printing my name below I consent to the following statement: I/We hereby understand and acknowledge that the services, training, programs and events held by The Body Engineers Inc. may expose me to many inherent risks, including accidents, injury, and/or illness. I/We assume all risk of injuries associated with participation including, but not limited to, falls, contact with other participants, and all other such risks being known and appreciated by me. I/We hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in activity. I/We acknowledge that I am physically fit and mentally capable of performing the physical activity I chose to participate in. After having read this waiver and knowing these facts, and in consideration of acceptance of my participation and The Body Engineers Inc. furnishing services to me, I agree, for myself and anyone entitles to act on my behalf, to HOLD HARMLESS, WAIVE AND RELEASE The Body Engineers Inc., its officers, agents employees, organizers, representatives, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in The Body Engineers Inc. services, training, programs, and/or events. By printing my name below electronically, I/We indicate that I/We have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntarily agree to its terms.
*
Thank you!
