Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist

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1 Health History Form: Beverly Hosford, Muscle Activation Techniques Specialist Name: Phone: Address: Birthdate: Age: EMERGENCY CONTACT Name: Phone: Are you seeing any medical practitioners such as MD, Osteopath, Chiropractor, Psychiatrist or Physical Therapist? Medical Practitioner: Office Phone: Medical Practitioner: Office Phone: Are you seeing any other practitioner outside of the traditional field of medicine such as an Acupuncturist, Massage Therapist, Rolfer, personal trainer, etc.? Are you currently taking any medications or supplements? Why? Have you ever had an X-Ray, MRI or CAT scan?

2 Have you ever had surgery? (including cosmetic) Have you ever broken any bones? Bone break: Date: Bone break: Date: Have you ever been involved in a car accident, or had a head injury such as whiplash, concussion or brain injury? Type of injury: Date: Type of injury: Date: Do you currently, or have you ever had artificial splints, orthotics, dental splints, or orthopedic braces? Do you have, or have you ever been diagnosed with an autoimmune disease or systemic disorder such as MS, Lupus, Fibromyalgia, Rheumatoid Arthritis, Chronic Fatigue, Epstein Barr, HIV/Aids, Candida, Cancer, Heart Disease, Diabetes, Lyme s disease or any other condition related to immune suppression or systemic inflammation? Diagnosis: Date: Treatment: Diagnosis: Date: Treatment: Do you have a history of food allergies and environmental sensitivities?

3 What do you do for a living? How does your job stress your body? Are you physically active? If so, what do you do for fitness and how often? Do any exercises, activities or body positions cause you pain or anxiety? What are your hobbies? How would you describe your general state of physical health and energy now? Have you ever had a negative reaction to any type of therapy (Physical Therapy, Chiropractic, Massage)? What results do you expect from your time and investment spent here? How much time are you willing to commit to Muscle Activation Techniques?

4 MUSCLE DISCOMFORT & INJURIES Age Describe the injury &feelings associated. When do you feel this? HEAD JAW NECK/CERVICAL MID BACK/ THORACIC LOW BACK ABDOMINAL/RIBS PELVIS/HIPS SHOULDER/ SCAPULA Rotator Cuff ELBOW Tennis/Golfers WRIST HAND KNEES ANKLES FEET

5 WAIVER OF LIABILITY AND INFORMED CONSENT RELEASE Cancellation Policy: I understand there is a 24-hour notice required for canceling all sessions. I understand that I will be charged for the full amount per session for appointments missed or rescheduled within the 24-hour time frame. Muscle Activation Techniques (MAT) Sessions: I understand that I have enrolled in a program of Muscle Activation Techniques offered by Beverly Hosford, MAT Certified Specialist. I acknowledge that Muscle Activation Techniques (MAT) is a form of stress on the body and may cause soreness and or discomfort during and/or after the session. I have been advised that participating in MAT based assessments and isometric exercises carry some unavoidable risks including injury or provoking symptoms related to pre-existing or provoking symptoms related to pre-existing or present conditions such as illness, disability, trauma, or surgery. I understand that although MAT has many benefits, MAT Certified Specialists do not carry a license to diagnose or make assessment regarding medical conditions of any kind. I also understand that medical evaluation is advisable before beginning any form of therapy or physical exercise. I have and will continue to keep Beverly Hosford fully informed of any physical condition or disability, which would affect my participation or safety in the Muscle Activation Techniques Sessions. I assume all risks of my participation in Muscle Activation Techniques sessions. I waive any claim, which I might otherwise bring against Beverly Hosford and her associates in practice if injuries occur from or in relation to participation in Muscle Activation Techniques Sessions. Client Name Date Client Signature

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