Name *

First Name

Last Name

Date of First Visit *

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Telephone # (home)

(###)

###

####

Telephone # (cell)

(###)

###

####

Telephone # (work)

(###)

###

####

Gender

Male

Female

Other

Date of Birth

MM

DD

YYYY

Do you feel pain in your chest when you perform physical activity? *

Yes

No

In the past month, have you had chest pain when you were not performing any physical activity?

Yes

No

Is your doctor currently prescribing any medication for your blood pressure or for a heart condition? *

Yes

No

Has your doctor ever said that you have a heart condition and that you should only perform physical activity recommended by a doctor? *

Yes

No

Do you lose your 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

Do you know of any other reason why you should not engage in physical activity? *

Yes

No

Are you hoping for in-person training sessions with Marshall? Or just distance coaching or programming?

Yes

No

Do you sleep well?

Yes

No

Previously

Awaken when rested?

Yes

No

Previously

Have dreams?

Yes

No

Previously

Spend time outside?

Yes

No

Previously

Whom do you live with?

Spouse

Partner

Parents

Children

Friends

Alone

Electrocardiogram

Yes

No

Electroencephalogram

Yes

No

Do you take or use Laxatives?

Current & past medications

Yes

No

Previously

Do you take or use Cortisone?

Current & past medications

Yes

No

Previously

Do you take or use Tranquilizers?

Current & past medications

Yes

No

Previously

Do you take or use Pain Relievers?

Yes

No

Previously

Do you take or use Appetite Suppressants?

Yes

No

Previously

Do you take or use Thyroid Medication?

Current & past medications

Yes

No

Previously

Do you take or use Antacids?

Current & past medications

Yes

No

Previously

Do you take or use Antibiotics?

Current & past medications

Yes

No

Previously

Do you take or use Sleeping Pills?

Current & past medications

Yes

No

Previously

Do you avoid canola oil?

Yes

No

Previously

Do you avoid cholesterol?

Yes No Previously

Option One

Option Two

Do you avoid saturated fat?

Yes

No

Previously

Do you avoid hydrogenated oils?

Yes

No

Previously

Do you avoid calories?

Yes

No

Previously

Do you add salt?

Yes

No

Previously

Do you eat three meals a day?

Yes

No

Previously

Do you eat out often?

Yes

No

Previously

Do you go on diets often?

Yes

No

Previously

Consume artificial sweeteners?

Yes

No

Previously

Do you drink coffee?

Yes

No

Previously

Do you drink black or green tea?

Yes

No

Previously

Do you drink cola or other sodas?

Yes

No

Previously

Do you consume artificial colors?

Yes

No

Previously

Enjoy your work?

Yes

No

Previously

Take vacations?

Yes

No

Previously

Have a supportive relationship?

Yes

No

Previously

Watch television?

Yes

No

Previously

Do you regularly read?

Yes

No

Previously

Do you carry a cell phone or other wireless device on your person regularly?

Yes

No

Previously

Where do you carry your cell phone or other wireless device?

Check all that apply

Pocket

Bag

Case

Other

Use alcoholic beverages?

Yes

No

Previously

Treated for alcoholism?

Yes

No

Previously

Any other drug use?

Yes

No

Previously

Do you use tobacco?

Yes

No

Previously

Smoked previously?

Yes

No

Previously

Use of chemical fertilizers, pesticides or herbicides at home/apt. complex?

Yes

No

Previously

Use a microwave? (select most accurate)

Household, Yard, Bodycare, Other

Always

Often

Sometimes

Rarely

Never

Treated for emotional issues?

Review of systems: Mental/Emotional

Yes

No

Previously

Mood swings?

Review of systems: Mental/Emotional

Yes

No

Previously

Considered/attempted suicide?

Review of systems: Mental/Emotional

Yes

No

Previously

Poor concentration?

Review of systems: Mental/Emotional

Yes

No

Previously

Depression?

Review of systems: Mental/Emotional

Yes

No

Previously

Anxiety or nervousness?

Review of systems: Mental/Emotional

Yes

No

Previously

Low motivation?

Review of systems: Mental/Emotional

Yes

No

Previously

Memory problems?

Review of systems: Mental/Emotional

Yes

No

Previously

Hypothyroid?

Review of systems: Endocrine

Yes

No

Previously

Heat intolerance?

Review of systems: Endocrine

Yes

No

Previously

Cold intolerance?

Review of systems: Endocrine

Yes

No

Previously

Seasonal depression?

Review of systems: Endocrine

Yes

No

Previously

Fatigue?

Review of systems: Endocrine

Yes

No

Previously

Hypoglycemia?

Review of systems: Endocrine

Yes

No

Previously

Diabetes?

Review of systems: Endocrine

Yes

No

Previously

Excessive thirst?

Review of systems: Endocrine

Yes

No

Previously

Excessive hunger?

Review of systems: Endocrine

Yes

No

Previously

Vaccinations?

Review of systems: Immune

Yes

No

Previously

Chronic Fatigue Syndrome?

Review of systems: Immune

Yes

No

Previously

Chronically swollen glands?

Review of systems: Immune

Yes

No

Previously

Reactions to vaccinations?

Review of systems: Immune

Yes

No

Previously

Chronic infections?

Review of systems: Immune

Yes

No

Previously

Slow wound healing?

Review of systems: Immune

Yes

No

Previously

Seizures?

Review of systems: Neurological

Yes

No

Previously

Muscle weakness?

Review of systems: Neurological

Yes

No

Previously

Loss of memory?

Review of systems: Neurological

Yes

No

Previously

Select frequency:

Review of systems: Neurological

Short term

Long term

Vertigo or dizziness?

Review of systems: Neurological

Yes

No

Previously

Paralysis?

Review of systems: Neurological

Yes

No

Previously

Numbness or tingling?

Review of systems: Neurological

Yes

No

Previously

Easily stressed?

Review of systems: Neurological

Yes

No

Previously

Strange tastes/smells?

Review of systems: Neurological

Yes

No

Previously

Loss of balance?

Review of systems: Neurological

Yes

No

Previously

Easy bleeding?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Easy bruising?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Deep leg pain in calves?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Varicose veins?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Anemia?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Blood clots?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Cold hands?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Cold feet?

Review of systems: Blood/Peripheral Vascular

Yes

No

Previously

Rashes, eczema, psoriasis?

Review of systems: Skin

Yes

No

Previously

Acne/boils?

Review of systems: Skin

Yes

No

Previously

Color change?

Review of systems: Skin

Yes

No

Previously

Lumps?

Review of systems: Skin

Yes

No

Previously

Hives?

Review of systems: Skin

Yes

No

Previously

Itching?

Review of systems: Skin

Yes

No

Previously

Perpetual hair loss?

Review of systems: Skin

Yes

No

Previously

Excessive perspiration?

Review of systems: Skin

Yes

No

Previously

Headaches?

Review of systems: Head

Yes

No

Previously

Migraines?

Review of systems: Head

Yes

No

Previously

Head Injury?

Review of systems: Head

Yes

No

Previously

Jaw/TMJ problems?

Review of systems: Head

Yes

No

Previously

"Floaters" in eyes?

Review of systems: Eyes

Yes

No

Previously

Impaired vision?

Review of systems: Eyes

Yes

No

Previously

Blurring?

Review of systems: Eyes

Yes

No

Previously

Color blindness?

Review of systems: Eyes

Yes

No

Previously

Double vision?

Review of systems: Eyes

Yes

No

Previously

Cataracts?

Review of systems: Eyes

Yes

No

Previously

Select:

Review of systems: Eyes

Glasses

Contacts

Eye pain/strain?

Review of systems: Eyes

Yes

No

Previously

Tearing or dryness?

Review of systems: Eyes

Yes

No

Previously

Glaucoma?

Review of systems: Eyes

Yes

No

Previously

Impaired hearing?

Review of systems: Ears

Yes

No

Previously

Earaches?

Review of systems: Ears

Yes

No

Previously

Ringing?

Review of systems: Eyes

Yes

No

Previously

Dizziness?

Review of systems: Ears

Yes

No

Previously

Frequent colds?

Review of systems: Nose/Sinuses

Yes

No

Previously

Stuffiness?

Review of systems: Nose/Sinuses

Yes

No

Previously

Sinus infections?

Review of systems: Nose/Sinuses

Yes

No

Previously

Nose bleeds?

Review of systems: Nose/Sinuses

Yes

No

Previously

Hay fever/allergies?

Review of systems: Nose/Sinuses

Yes

No

Previously

Loss of smell or taste?

Review of systems: Nose/Sinuses

Yes

No

Previously

Other

Review of systems: Nose/Sinuses

Yes

No

Previously

Frequent sore throat?

Review of systems: Mouth/Throat

Yes

No

Previously

Gum problems?

Review of systems: Mouth/Throat

Yes

No

Previously

Teeth grinding?

Review of systems: Mouth/Throat

Yes

No

Previously

Dental cavities?

Review of systems: Mouth/Throat

Yes

No

Previously

Profuse saliva?

Review of systems: Mouth/Throat

Yes

No

Previously

Sore tongue/lips?

Review of systems: Mouth/Throat

Yes

No

Previously

Hoarseness/often clearing throat?

Review of systems: Mouth/Throat

Yes

No

Previously

Mercury fillings?

Review of systems: Mouth/Throat

Yes

No

Previously

Lumps?

Review of systems: Neck

Yes

No

Previously

Goiter?

Review of systems: Neck

Yes

No

Previously

Swollen glands/lymph nodes?

Review of systems: Neck

Yes

No

Previously

Pain or stiffness?

Review of systems: Neck

Yes

No

Previously

Cough?

Review of systems: Respiratory

Yes

No

Previously

Sputum?

Review of systems: Respiratory

Yes

No

Previously

Spitting up blood?

Review of systems: Respiratory

Yes

No

Previously

Asthma?

Review of systems: Respiratory

Yes

No

Previously

Pneumonia?

Review of systems: Respiratory

Yes

No

Previously

Emphysema?

Review of systems: Respiratory

Yes

No

Previously

Pain on breathing?

Review of systems: Respiratory

Yes

No

Previously

Tuberculosis?

Review of systems: Respiratory

Yes

No

Previously

Shortness of breath lying down?

Review of systems: Respiratory

Yes

No

Previously

Wheezing?

Review of systems: Respiratory

Yes

No

Previously

Bronchitis?

Review of systems: Respiratory

Yes

No

Previously

Pleurisy?

Review of systems: Respiratory

Yes

No

Previously

Heart disease?

Review of systems: Cardiovascular

Yes

No

Previously

High blood pressure?

Review of systems: Cardiovascular

Yes

No

Previously

Low blood pressure?

Review of systems: Cardiovascular

Yes

No

Previously

Blood clots?

Review of systems: Cardiovascular

Yes

No

Previously

Phlebitis (vein inflammation)?

Review of systems: Cardiovascular

Yes

No

Previously

Rheumatic fever?

Review of systems: Cardiovascular

Yes

No

Previously

High cholesterol?

Review of systems: Cardiovascular

Yes

No

Previously

Stroke?

Review of systems: Cardiovascular

Yes

No

Previously

Angina?

Review of systems: Cardiovascular

Yes

No

Previously

Murmurs?

Review of systems: Cardiovascular

Yes

No

Previously

Swelling in ankles?

Review of systems: Cardiovascular

Yes

No

Previously

Fainting?

Review of systems: Cardiovascular

Yes

No

Previously

Heart palpitations/fluttering?

Review of systems: Cardiovascular

Yes

No

Previously

Chest pain?

Review of systems: Cardiovascular

Yes

No

Previously

Heart attack?

Review of systems: Cardiovascular

Yes

No

Previously

Aneurysm?

Review of systems: Cardiovascular

Yes

No

Previously

Trouble swallowing?

Review of systems: Gastrointestinal

Yes

No

Previously

Increase in thirst?

Review of systems: Gastrointestinal

Yes

No

Previously

Decrease in thirst?

Review of systems: Gastrointestinal

Yes

No

Previously

Nausea?

Review of systems: Gastrointestinal

Yes

No

Previously

Vomiting?

Review of systems: Gastrointestinal

Yes

No

Previously

Vomiting up blood?

Review of systems: Gastrointestinal

Yes

No

Previously

Pain or cramps?

Review of systems: Gastrointestinal

Yes

No

Previously

Belching?

Review of systems: Gastrointestinal

Yes

No

Previously

Passing gas?

Review of systems: Gastrointestinal

Yes

No

Previously

Mucus in the stool?

Review of systems: Gastrointestinal

Yes

No

Previously

Jaundice (yellow skin)?

Review of systems: Gastrointestinal

Yes

No

Previously

Liver disease?

Review of systems: Gastrointestinal

Yes

No

Previously

Heartburn?

Review of systems: Gastrointestinal

Yes

No

Probably

Increase in appetite?

Review of systems: Gastrointestinal

Yes

No

Previously

Decrease in appetite?

Review of systems: Gastrointestinal

Yes

No

Probably

Constipation?

Review of systems: Gastrointestinal

Yes

No

Previously

Diarrhea?

Review of systems: Gastrointestinal

Yes

No

Previously

Blood in the stool?

Review of systems: Gastrointestinal

Yes

No

Previously

Undigested food in the stool?

Review of systems: Gastrointestinal

Yes

No

Previously

Gall bladder disease?

Review of systems: Gastrointestinal

Yes

No

Previously

Ulcers?

Review of systems: Gastrointestinal

Yes

No

Previously

Hemorrhoids?

Review of systems: Gastrointestinal

Yes

No

Previously

Pain on urination?

Review of systems: Urinary

Yes

No

Previously

Frequent infections?

Option One

Option Two

Increased urgency or frequency?

Review of systems: Urinary

Yes

No

Previously

Inability to hold urine?

Review of systems: Urinary

Yes

No

Previously

Kidney stones?

Review of systems: Urinary

Yes

No

Previously

Hernias?

Review of systems: Males

Yes

No

Previously

Testicular pain?

Review of systems: Males

Yes

No

Previously

Prostate disease?

Review of systems: Males

Yes

No

Previously

Are you sexually active?

Review of systems: Males

Yes

No

Previously

Pain during intercourse?

Review of systems: Males

Yes

No

Previously

Premature ejaculation?

Review of systems: Males

Yes

No

Previously

Impotence?

Review of systems: Males

Yes

No

Previously

Herpes?

Review of systems: Males

Yes

No

Previously

Testicular masses?

Review of systems: Males

Yes

No

Previously

Do you do testicle self-exams?

Review of systems: Males

Yes

No

Previously

Low sexual desire/ Libido?

Review of systems: Males

Yes

No

Previously

Discharge or sores?

Review of systems: Males

Yes

No

Previously

Chlamydia?

Review of systems: Males

Yes

No

Previously

Gonorrhea?

Review of systems: Males

Yes

No

Previously

Condyloma?

Review of systems: Males

Yes

No

Previously

Syphilis?

Review of systems: Males

Yes

No

Previously

Heavy or excessive flow?

Review of systems: Females

Yes

No

Previously

PMS?

Review of systems: Females

Yes

No

Previously

Ovarian cysts?

Review of systems: Females

Yes

No

Previously

Endometriosis?

Review of systems: Females

Yes

No

Previously

Low sexual desire?

Review of systems: Females

Yes

No

Previously

Are you sexually active?

Review of systems: Females

Yes

No

Previously

Gonorrhea?

Review of systems: Females

Yes

No

Previously

Herpes?

Review of systems: Females

Yes

No

Previously

Chlamydia?

Review of systems: Females

Yes

No

Previously

Condyloma?

Review of systems: Females

Yes

No

Previously

Syphilis?

Review of systems: Females

Yes

No

Previously

Are cycles regular?

Review of systems: Females

Yes

No

Previously

Bleeding between cycles?

Review of systems: Females

Yes

No

Previously

Pain during intercourse?

Review of systems: Females

Yes

No

Previously

Clotting?

Review of systems: Females

Yes

No

Previously

Discharge?

Review of systems: Females

Yes

No

Previously

Birth control?

Review of systems: Females

Yes

No

Previously

Difficulty conceiving?

Review of systems: Females

Yes

No

Previously

Menopausal symptoms?

Review of systems: Females

Yes

No

Previously

Abnormal PAP?

Review of systems: Females

Yes

No

Previously

Cervical dysplasia?

Review of systems: Females

Yes

No

Previously

Do you do breast self-exams?

Review of systems: Females

Yes

No

Previously

Breast lumps?

Review of systems: Females

Yes

No

Previously

Breast pain/tenderness?

Review of systems: Females

Yes

No

Previously

Joint pain/stiffness (please specify below)

Review of systems: Musculoskeletal

Yes

No

Previously

Left Hand (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Right Hand (fingers: 1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Left Foot (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Right Foot (1-5) - Joint pain/stiffness

Review of systems: Musculoskeletal

1

2

3

4

5

Appendages

Review of systems: Musculoskeletal

Left wrist

Right wrist

Left elbow

Right elbow

Left shoulder

Right shoulder

Left hip

Right hip

Left knee

Right knee

Left ankle

Right ankle

Left upper back

Right upper back

Left mid back

Right mid back

Left low back

Right low back

Broken bones?

Review of systems: Musculoskeletal

Yes

No

Previously

Muscle spasms or cramps?

Review of systems: Musculoskeletal

Yes

No

Previously

Arthritis?

Review of systems: Musculoskeletal

Yes

No

Previously

Muscular pain or weakness?

Review of systems: Musculoskeletal

Yes

No

Previously

Sciatica?

Review of systems: Musculoskeletal

Yes

No

Previously