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Physical Therapy - coming in June

If you have already experienced the services offered by our team, you are well aware of our goal oriented, community building approach to personal health and wellness. If not, then welcome to a whole new approach to your personal well being.

With Personal Fitness Coaching serving as the foundation of our company, our physical therapy philosophy, lead by James Harris, M.P.T., is a natural synergy of traditional physical therapy and total body wellness. We assess the individual in relationship to the injury or condition, then develop a proactive treatment plan to manage the source of limitation. Once functional limitations are resolved or managed, we can design a total body wellness plan, with orthopedic considerations, goals, and lifestyle in mind.

Our Personal Fitness Coaching Team can also provide continued support and guidance as you reclaim your optimal state and prevent future injury. Please contact us today to discuss your options.

Frequently Asked Questions
Medical / Exercise History Questionnaire

FREQUENTLY ASKED QUESTIONS

Can you describe to me exactly what "corrective strategies" are?
Corrective strategies are exercises designed to help you return to your optimal state of movement and function. These “strategies” are often low impact; minimal resistance exercises designed to promote proper biomechanical rhythm and improved core function. With guidance, you will be able to use your body’s own natural “corrective” properties to reduce, and often eliminate, painful motions.

Do I need a prescription from my doctor to receive Physical Therapy?
Yes, the state of Missouri currently does not allow physical therapists to practice without a written physician referral. Once treatment has been prescribed we will work with you, your insurance provider, and your physician to develop the most appropriate plan of care for you.

After our prescribed Physical Therapy sessions are over, can I continue personal training with you?
Absolutely, our group of Personal Fitness Coaches have extensive knowledge and experience in the areas of weight management, athletic development, and even aquatics. Whether gearing up for an upcoming triathlon or simply wanting to prevent injury reoccurrence, our team of qualified coaches will be with you every step of the way.

Do you offer "in home" therapy?
Typically no, however, certain considerations may be made. We would love to work with you in any capacity in order to help you return to a positive wellness oriented lifestyle. Please contact us with your specific questions regarding in-home therapeutic services.

(If you have any other questions not addressed here, please, email Physical Therapist, James Harris or Dave Reddy

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MEDICAL / EXERCISE QUESTIONNAIRE

Thank you for taking the time to fill out our questionnaire, and please, keep in mind, the more you tell us, the better job we can do individualizing your fitness program. This questionnaire helps to maximize our time efficiency with you, especially during our first meeting, allowing us to follow up with specific details about what you are hoping to receive from our services. Thanks again, we look forward to meeting you, and will be contacting you as soon as possible.

Contact Information

Last Name

First Name

Work Phone

Home Phone

Mobile Phone

Email

How did you hear about our services and/or web site?

Online Search

Referral

Inquiry at THE HEIGHTS

Other

Is it OK if we add your name to our Newsletter / Program Update Email List? (Emails go out every 4-6 weeks to update and announce new programs within the EBF Community.) Yes No

While we cannot guarantee you will work with the trainer you choose below, please let us know if you have spoken with anyone, or would like to work with any one in particular. We attempt to match each person with the best fit for your specific needs and availabilities.

Rebecca Boillat

Megan Hunsaker

James Harris

Other

Personal / Lifestyle Information
Gender Male Female

Age Birth Date

Height ft in

Has your body weight fluctuated in the past 1-5 years?

What was your weight at age 18? lbs

How may hours of sleep do you typically get a night?

Do you or have you smoked? Yes No If so, when, and how many a day?
Do you live with someone who smokes? Yes No

Do you drink alcoholic beverages? Yes No If so, which do you consume, and how much of each? (Click all that apply below:)

Comments:

Do you travel often for work? Yes No
If so, how often, and does it have an effect on your exercise?

Did someone refer you or recommend you begin exercising? Yes No
If so, who? Doctor Friend Sibling Spouse Other

Exercise History
Are you currently involved in a regular exercise program? Yes No

How often do you exercise? (Exercise, for now can be defined as any consistent physical activity, i.e. walking, jogging, lifting weights, or rec sports lasting more than 30 minutes continually at a time.)
Never Rarely 1 x / week Several x / week Daily

Workout Venue Fitness Center or Health Club Home Outside (Walk/Run) Other
What fitness center or "other venue"?

How long have you been a member at your present health club / fitness center?

What does a typical workout consist of? (This can be any consistent physical activity you participate in.) Click all that apply, then please comment in the box below to give me an idea of a typical workout:

Walking outside
Treadmill
Elliptical Machine
Stationary Bike
Walking Track
Swimming
Aerobics Class
Jogging / Running

Cybex Machines
Free Weights
Stretching
Recreation Sport
Yoga
Pilates
I really don't have a typical workout, hence, I called you.
Other (comment below)

"Typical Workout" Details"

Tell me about your very last workout (Continue below or tell me more yourself):
I warmed up with . . . My cardio consisted of . . . For strength, I did . . .

How long did your workout last?

What did you do, more or less? (Choose all that apply by Ctrl-clicking each selection)

What was your focus? (Choose all that apply by Ctrl-clicking each selection)

Please include any other useful details below: (i.e. did you feel better or worse at the end of the workout?)
I felt ready to take on the world upon exiting the building!

Physical Activity Readiness Questionnaire (PAR-Q)
For most people, physical activity should not pose any problem or hazard. PAR-Q has been designed to identify the small number of adults for whom physical activity might be inappropriate or those who should have medical advice concerning the type of activity most suitable for them. Please read and check the yes or no opposite the question.

Yes No	Has your physician said you have a heart condition or should only do exercises recommended by a physician?
Yes No	When you do physical activity, do you feel pain in your chest?
Yes No	When at rest, or not doing physical activity, have you had chest pain in the past month?
Yes No	Do you ever lose consciousness or do you lose your balance because of dizziness?
Yes No	Are you currently taking prescribed medications for your blood pressure or heart condition?
Yes No	Are you over the age of 65?

*If your health changes and answers above are altered, please notify your personal trainer, and we will discuss seeking guidance from a physician.

Personal Medical History
If you do take medications, please list them below.
Med , dosage , x / day

Have you had any surgeries that may have an effect on your exercise performance? Yes No
List and briefly describe below:
Surgery, Year, Any post-surgical complications?

Do you have any other aches and pains (i.e. low back) that hinder or may hinder your exercising?
Yes No

Have you ever been diagnosed with, or experienced any of the following? (Click all that apply)

Rapid / Irregular Heart Beat
Hypertension
Calf pain with exercise
Varicose veins
Stroke

High blood cholesterol
High blood triglycerides
History of blood clots
Shortness of breath
Glucose Intolerance

Do you take medications for any of the conditions selected here?
For my hypertension, I take . . .

If you are over the age of 60, have you had a bone density test recently? Yes No

Family Medical History
If known, please click on all of the following conditions your parents, grandparents, or siblings have or have had:

Hypertension
Cancer
Diabetes
Stroke
Heart Attack
Other Heart Blockage / Problems

Obesity
Arthritis
Osteoporosis
Asthma
Anemia
Epilepsy / Seizures

Questions for FEMALES Only
Have you ever been pregnant? Yes No If so, how many times?

Are you currently expecting? Yes No If so, (Congratulations!) what is the present due date?

Do you have regular menstrual cycles? Yes No

Are you Pre-menopausal Post-menopausal

Goals Overview (Select all that apply)

Improve exercise habits
Learn more about my body
Learn more about nutrition
General fitness
Weight management
Upper body strength
Lower body strength
Improve flexibility

Improve posture
Get in shape for event
Lifestyle change
Just had baby . . .
Sport specific training
Increase muscle size
Wanting more energy
Other (explain below)

Please add any other goal related specifics (in your own words) below:

In a nutshell, what motivates you? What motivates you to work towards the goals listed above? What has motivated you in the past?

Please discuss any specific motivators above, and check anything that may apply, included in the list below:

Overall health benefits
Group (support) settings (T.O.P.S., Wt. Watchers, etc.)
Looking at old pictures of your self
Positive reinforcement
Negative reinforcemet

Hearing others success stories (on TV, friends)
Reading motivational articles, books
Success or previous success on the playing field
Desire for a better quality of life
Desire to keep up with the kids (grand kids)

What has happened, if ever in the past, that may have caused you to lose this motivation, or fall off track?
Did not see any results
Got bored
Not enough direction, not really sure what to do or how to progress with exercise
Personal life experience (Career change, had baby, injury, other)
Too busy with work and/or family, (long hours, lots of travel, family obligations)
It just happened, I don't really have that great of an excuse
Anything else? Please explain:

Commitment
How many days a week can you or are you willing to commit to these goals? (Give or take a day)

How much time do you have per workout session?

The EBF Personal Trainers are here to help you as much as you can or want, therefore, how many times do you think you'll want to meet to get you on track?

Nutrition
How would you rate your nutritional habits as of today?

Do you normally eat breakfast? Yes No

What was your breakfast this morning? Is this typical?

Are you a vegetarian? Yes No

How many meals do you typically eat in a day? (A snack is considered a meal.)

How much caffeine do you consume daily? (Cup of coffee = 100 mg , 12 oz soda = 50-60 mg , tablet = 200 mg)
None 50-100 mg 100-150 mg 200+ mg Not Sure

What form is it in? Coffee Regular Soda Diet Soda Tea Energy Drink Other

How many times do you eat out a week?

Do you or have you supplemented with any of the following (Check all that apply):

Multi-vitamin
Individual vitamins / minerals
Protein powder
Herbal supplements
"Energy supplements"
Supplements for joint support

Creatine
Amino acids
"Fat Burners"
"Fat Blockers"
Fiber supplement
Other

Can you tell us a little bit about the supplements you take, i.e., type of protein, what individual vitamins, what brand fat burner?

How would you describe your "nutritional focus"?
I have no nutritional focus
Low Fat
Low Carb
Everything in moderation
Small portion sizes
Grilled chicken & spinach during the week, wings and beer on the weekend
Other (Explain below):

Do you follow, or have you followed a specific diet? If so, check the appropriate one and explain below.
South Beach Atkins Weight Watchers Jenny Craig Zone Diet 40-30-30
Other

Fitness Information
Where do you get most of your health and fitness information? (Click all that apply.)
Fitness Magazines Internet Newspaper Doctor Other Magazines TV
Book(s) Other

Have you ever ordered a fitness product online? (Book, DVD, Exercise Equipment)

Scheduling An Appointment / Availability
In the text box below, please tell us your available days and times of day that are good for you. This is very important to answer as it may determine what trainer is available during this time. Thank you.

Let me know if you have any other questions or comments.

Thank you for taking the time. Please click the SUBMIT button only once, it may take a minute to process.

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