Physical Therapy Intake

Athletic History
Please tell us about your past and present athletic activities*
Add more rows with the + if needed.
Sport/Activity Years of Participation Additional Details or Info

Training History
Please tell us what your training regiment has consisted of over the last 6 months*
Do you currently have a warm up that you do consistently?*
- Yes
- No
Please tell us about your warm up*
Do you currently have a recovery plan post workout?*
- Yes
- No
Please tell us about your recovery plan*
Do you currently work on mobility outside of your warm up / recovery plan?*
ie Rest days, specific mobility days, ROM WOD
- Yes
- No
Please tell us about your mobility work*

Lifestyle
What is your occupation?*
Different occupations effect the body in varying ways, this will allow us to customize your plan of care accordingly.
Do you currently follow a nutritional plan?*
- Yes
- No
Please describe your current nutritional plan?*
What is your preferred method of communication with HELIYO?
- Text
- Email
- No Preference

Surgeries and Medical Procedures
Have you experienced an surgeries/medical procedures in the past?*
- Yes
- No
Please list all surgeries and/or medical procedures below*
Add more rows with the + if needed.
Date of Surgery/Procedure Type of Surgery/Procedure What Cause/Event Lead to This? Resolved or Ongoing Condition?

Injuries
Have you experience any injuries in the past?*
Injuries involving muscles, tendons, ligaments, and bones
- Yes
- No
Please list all injuries below*
Add more rows with the + if needed.
Date of Injury Type of Injury How Did Injury Take Place? Resolved or Ongoing?

Serious Health Conditions
Have you experienced any serious health conditions in the past?*
- Yes
- No
Please list all health conditions below*
Add more rows with the + if needed.
Date of Health Condition Type of Health Condition Resolved or Ongoing Condition?
Do you have any additional health information that you would like to disclose?*
- Yes
- No
*

Current State of Your Body
Are you currently experiencing any aches and/or pains?*
- Yes
- No
Please list all aches and/or pains*
Add more rows with the + if needed.
Location Description of Pain/Ache Date of Onset How did it start?
Does a physician or physical therapist currently monitor or prescribe exercises for you?*
- Yes
- No
If yes please describe who and what for*
Anything else you would like to tell us about the current state of your body?*
- Yes
- No
If yes, please elaborate*

Athletic History