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Client Questionnaire
Client Questionnaire
All information is kept strictly confidential and will never be shared with a 3rd party.
Name
*
Full Address
*
Phone Number
*
Email Address
*
Date of Birth
*
Gender
*
Occupation
*
Name & Phone Number of your Medical Doctor. If you do not have a family doctor please indicate that in the space provided.
*
Whom may we contact in case of emergency? NAME & PHONE NUMBER
*
Reasons for consulting SHAPE
*
Briefly describe your medical history
*
Do you currently take any medications, vitamins or other supplements?
*
Yes
No
If you answered yes to above please list what you are taking
Has your doctor ever said that you have a heart condition and that you should only do physical activity recommended by a doctor?
*
Yes
No
Do you feel pain in your chest when you do physical activity?
*
Yes
No
In the past month, have you had chest pain when you were not doing physical activity?
*
Yes
No
Do you lose balance because of dizziness or do you ever lose consciousness?
*
Yes
No
Do you have a bone or joint problem that could be made worse by a change in your physical activity?
*
Yes
No
Is your doctor currently prescribing drugs (for example, water pills) for your blood pressure or other heart condition?
*
Yes
No
Have you ever tested HIV positive or been diagnosed with cancer?
*
Yes
No
Are you 18 years of age or older? You may submit this form but will be required to supply the signature of a parent or guardian on your first visit to SHAPE.
*
Yes
No
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LOCATION
SHAPE Health & Wellness Centre
35 Coldwater Rd.
Toronto ON M3B1Y8
CALL:
416.929.8444
HOURS
Mon. - Thurs. 6am - 9pm
Fri. 6am - 6pm
Sat. 8am - 6pm
Sun. 9am - 4pm
EMAIL
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IINTERVIEW WITH DR. SENDER DEUTSCH
SHAPE Health & Wellness Centre
35 Coldwater Rd.
Toronto ON M3B1Y8
CALL:
416.929.8444
HOURS
Mon. - Thurs. 6am - 9pm
Fri. 6am - 6pm
Sat. 8am - 6pm
Sun. 9am - 4pm