Email Address
Note: I only work with men up to 220 lbs
Click Here for Weight Exceptions
Hypoglycemia
 Diabetes
 Flu / Cold
Are you under the care of a Health Care Professional?
If Yes, Health Care Providers Name.
List ANY and ALL Medications you are taking.
Check any activities you currently enjoy or recently enjoyed.
Skating
Rodeo
Share your typical day at work.
Toting / Carrying Loads
High Stress
Travel by air often
Pushing Loads Often
Medium Stress
Travel by boat often
Pulling Loads Often
Low Stress
Work at home
No Stress
 Squatting Often
Experience anger often
Indoor Work
Forward Reaching
Experience happy often
Outdoor Work
 Side Reaching
Exper. Depression Often
Indoor / Outdoor Work
 Backward Reaching
Suffer with pain at work
Sit at Desk often
 Driving Often
Often on-call.
Work With Public
Walking Often
Often on phone
Lots of responsibility
Standing Often
20 to 40 hours a week
Get up and down often
 Fulfilling Work
40 to 50 hours a week
Often reach over head.
 Not Fulfilling
60 to 70 hours a week
Often bend at waist
 I love my job
70 to 80 hours a week
I like my job
Often twist / turn body
Often on computer
Often Climb stairs
 My jobs OK
Exper. Anxiety often
Often climb ladders
 I hate my job
Side Step often
Arms out from body often
 Retired but Not Active
I work First Shift
In tight confinement
Retired and Active
I work Second Shift
Travel by car often
Lifting Involved often
I work Third Shift
Address
City
State
Zip
Birth Date
Height
Weight
Please check any of the following conditions you are experiencing.
Emotional Changes
Heart Ailment
Infectious Condition
Kidney Ailment
Cancer
Chronic / Acute Pain
Neck / Spine Injury
Fibromyalgia
Headaches
Phlebitis
Allergies
Digestive Problems
Ulcerated Colon
Joint Discomfort
Skin Disorders
Fever
Swelling / Puffiness
Varicose Veins
Blood Clots
High Blood Pressure
Arthritis
Osteoporosis
Carpel Tunnel Syndrome
Fibromyalgia
Headaches
Aerobics
Baseball
Basket Ball
Biking
Blading
Climbing
Field and Track
Football
Golf
Gymnastics
Hiking
Horseback
Snow Skiing / Boarding
Jogging
Marathon
Racquetball
Running
Rugby
Soccer
Running
Skate Boarding
Softball
Speed Walking
Swimming
Tennis
Tri athlon
Volley Ball
Walking
Athletes Foot
Plantar Warts
Allergy to Sesame Seed
Water Ski
Weight Lifting
Other Physical Activity
First Name
Last Name
Phone
T.M.J Syndrome
Sleeplessness
Occupation
About You...