RESTORATIVE FITNESS INTAKE
Caution Statement:
We encourage all members to talk to their doctor before starting this or any other fitness program to determine if becoming more physically active is beneficial to your health. We strongly encourage you to consult your doctor regarding the physical activities you wish to participate in within this program. Should you choose to consult with your physician, our fitness and health professionals are happy to structure your program based on their advice.
Please use caution and potentially delay increasing physical activity if you:
• are not feeling well because of temporary illness such as cold or fever -- please, wait until you feel better
• are or may be pregnant - talk to your doctor before you start becoming more active.
• have health changes and/or your physical guidelines to follow have been (or will be) updated by your physician -- tell your fitness or
• health professional and consult your doctor on whether you should change your physical activity plan.
1. Today’s Date:
PATIENT INFORMATION
2. Patient Name:
3. DOB:
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
2. Minor Patient Name: <CHILDFIRSTNAME> <CHILDLASTNAME>
3. Minor DOB: <CHILDBIRTHDAY>
4. Gender: Male Female Other: Personal Gender Preference(s):
5. Phone:
6. Email:
7. Address: Street Address City , State Zip
8. What service are you requesting? (Please check all that apply):
Physical Therapy Massage Therapy Cupping Postural Restoration (PRI)
Acupuncture Energy Healing Restorative Fitness Mental Performance
Nutrition/Dietician Chiropractic Care Other:
9. Reason for Visit/Current Pain or Symptoms:
10. How did you hear about us? (Please check all that apply)
Family/Friend: Doctor/Medical Office:
Google Social Media Website (Thrivevb.com) Advertisement:
11. Name of referral: 11b. Relationship:
IN CASE OF EMERGENCY
*Please provide the name and contact information of a Relative or Friend below.
12. *Emergency Contact:
13. *Phone:
14. *Relationship:
15. Is this person a patient here? Yes No
CANCELLATION POLICY
Cancellation Policy: At Thrive we truly desire to empower you in your health + fitness goals and we know that attendance at your appointment is important in order for you to reach those goals. Your time here is important to us + we value your commitment to the work. We understand accidents, emergencies, + other scheduling conficts happen; however we have put in place a policy that respects everyone's time + eliminates any confusion to help keep the gym + clinic operating optimally to the benefit of all members.
16. Please Initial below:
I understand that any Restorative Fitness appointment cancelled the day of the appointment will be considered a late cancellation and the appointment will be charged at its full scheduled rate, unless the appointment is able to be rescheduled in the same day.
All information above is completed to the best of my knowledge. I understand it is my responsibility to communicate with the providers if I feel uncomfortable or wish to refuse to continue treatment/service at any time. My voluntary participation along with this consent shall be on-going for the time period and participation in any service menu item -- included but not limited to; Fitness Training, Physical Therapy, Massage Therapy, Cupping Recovery Services, Mental Performance, Chiropractic Care, Acupuncture, Nutrition, Energy Healing, and any other Health and Wellness Service(s) offered at Thrive Proactive Health.
HEALTH EVALUATION + PHYSICAL ACTIVITY READINESS
Caution Statement: We encourage all members to talk to their doctor before starting a new fitness program.
We strongly encourage you to consult your doctor regarding the physical activities you wish to participate in within this program. Please use caution and potentially delay increasing physical activity if you:
➔ are not feeling well because of temporary illness such as a cold or fever -- please, wait until you feel better.
➔ are or may be pregnant - talk to your doctor before becoming more active.
➔ have recent health changes and/or are under new guidelines set by your physician -- tell your fitness or health professional and consult your doctor on whether you should change your physical activity plan.
1. Age: Height: ft in Weight: lbs Weight 1 year ago: lbs Average BP: /
2. Physician's Name: Physician’s Phone #:
3. Date of last Physical Examination performed by a physician:
4. Does your physician know you are participating in this program?
Yes No
5. Please list any medications or drugs you are currently taking, if any:
6. Has your doctor ever advised activity restrictions due to a heart condition?
Yes No
7. Do you feel pain in your chest when you do physical activity?
Yes No
8. In the past month, have you had chest pain when you were not doing physical activity?
Yes No
9. Do you lose your balance because of dizziness or do you ever lose consciousness?
Yes No
10. Do you have a bone/joint problem that could be worsened by a change in your physical activity?
Yes No
11. Is there any other reason why you think you should not do physical activity?
Yes No
PRESENT / PAST HISTORY
1. Have you had or do you currently have any of the following conditions? (Check if yes)
Recent surgeries or operations (12 months or less)
Any Chronic Illness or condition
High blood pressure
Seizures
Lung disease
Heart attack or known heart disease
Difficulty with physical exercise
Pregnancy (now or within last 3 months)
History of breathing or lung problem
Muscle or joint disorder (back, shoulder knee etc.)
Diabetes
Thyroid Condition
Smoking
Obesity
High Cholesterol
Migraines or headaches
Fainting or dizziness
Shortness of breath at rest or with mild exertion
Palpitations or tachycardia (unusually strong or rapid beat)
Pain, discomfort in the chest, neck, jaw, arms, or other areas
Neurological Conditions Parkinson’s, Gehrig’s, etc.
Unusual fatigue or shortness of breath with usual activities
Cancer
Advice from physician not to exercise
Temporary loss of visual acuity, speech, short-term numbness or weakness in one side of body
Hernia or conditions aggravated by heavy resistance exercise
Edema or Intermittent claudication (swelling of ankles or calf cramping)
History of heart problems, chest pain, murmur irregular heartbeat, and/or strokes
Orthopnea (the need to sit up to breathe comfortably) or paroxysmal (sudden, unexpected attack) or nocturnal dyspnea (shortness of breath at night)
Other (explain below)
*Please explain any Yes answers or Other:
FAMILY HISTORY
1. Have any of your first-degree relatives (parent, sibling, or child) experienced the following conditions? (Check if yes.)*In addition, please identify at what age the condition occurred.
Heart attack
Heart operation (Bypass surgery, Angioplasty, Coronary Stent placement)
Congenital heart disease
High blood pressure
High cholesterol
Diabetes
Other major illness:
*Please explain any checked items:
PHYSICAL CONCERNS/ LIMITATIONS
1. Is there anywhere that you experience regular or occasional discomfort? (check all that apply)
Feet/Ankles
Knees
Hips/Pelvis
Low back
Mid Spine
Neck
Shoulders
Elbows
Hand/wrist
2. Please detail any previous injuries, surgeries, nagging or chronic pains.
ACTIVITY HISTORY + INVENTORY
1. What types of Exercise Programs have you participated in before, if any?
2. What, if any, concerns or hesitations do you have going into a new exercise program?
3. What do you enjoy Most/Least about exercising or participating in exercise programs?
➔ Most:
➔ Least:
4. Please use the following to describe your current exercise program at this time, if any:
➔ How long? (average workout duration - minutes/hours/etc.)
➔ How often? Circle One: Occasionally 1-3x Monthly 1-2x Weekly 2-4x Weekly 4-7x Weekly Daily
➔ Average Intensity level? Circle One: Low Moderate Vigorous
5. Rate the following on a scale of 1-10:
➔ Overall exercise level -- Beginner (1) to Advanced (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
➔ Current level of flexibility -- Low (1) to High (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
➔ Current level of strength -- Low (1) to High (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
➔ Current level of conditioning -- Low (1) to High (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
➔ Current nutritional habits -- Poor (1) to Ideal (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
➔ Current stress level -- Low (1) to High (10)
Circle One: 1 2 3 4 5 6 7 8 9 10
6. Are there any forms of exercise equipment you have used that you liked/didn’t like/ or presented difficulties?
(EX: Dumbbells, TRX, Kettlebells, Medicine Balls)
➔ Like:
➔ Don’t Like:
➔ Present Difficulties:
7. Do you experience any pain, limitations or difficulties with the following? (Please Explain)
➔ Specific Exercises:
➔ Daily Activities:
➔ Specific Tasks:
8. Is there anything that you can't do now or that you'd like to be able to do?
9. Outside of exercise what other activities, interests, or hobbies do you participate in?
10. How would you state your top 3 goals for fitness and overall health and wellbeing?
11. Is there anything else you would want us to know about you before you begin this program?
Thrive Restorative Fitness Program Informed Consent
“I, , have enrolled in the Restorative Fitness program of physical activity including but not limited to aerobic and resistance exercise, and various equipment offered by Thrive. I hereby affirm that I am in good physical condition and do not suffer from any disability which would prevent or limit my participation in this program.
Before I enter the Restorative Fitness Program, I will honestly and fully complete a Medical History and Risk Evaluation. The purpose of this questionnaire is to detect any condition which would indicate that I should not engage in this or any exercise program without the expressed permission of a physician. Should there be any condition not mentioned in this evaluation of which I am aware, and said condition could cause me possible distress, I will inform the Restorative Fitness director in writing.
I agree to promptly report to the Thrive Fitness Director and or staff of any and all signs and symptoms of possible distress while participating.
In consideration of my participation in an exercise program, I, , for me, my heirs, and assigns, hereby release Thrive, its employees and owners from any claims, demands and causes of action arising from my participation in Restorative Fitness.
I fully understand that a possible injury to myself may occur as a result of my participation in Restorative Fitness.
I, , hereby release Thrive from any liability now or in the future including but not limited to, heart attacks, muscle strains, pulls, tears, broken bones, heat prostration, knee, hip, low back, foot injuries and any other illness, soreness or injury however caused, occurring during or after my participation in the Restorative Fitness Program.
I hereby affirm that I have read and fully understand the above."
By signing this waiver, I verify the above information is complete and accurate to the best of my knowledge.
CONSENT FOR PARTICIPATION / WAIVER
CONSENT FOR PARTICIPATION / WAIVER
I voluntarily consent to the elective services at Thrive Proactive Health. I am aware that it is my right to accept or refuse any treatment/services offered to me. I acknowledge and understand that no guarantee has been made to me as to the results that may be obtained from such treatment/services. I understand that I will have the right to refuse to continue treatment/services at any time. It is this clinic’s sincere mission to educate and empower me through my health and wellness journey. Therefore, if modalities, exercises, techniques or any procedure is not understood, it is my responsibility to obtain a clearer understanding of what the provider’s objectives and outcomes are, and how he/she is trying to achieve them. This consent shall be on-going for the treatment period and participation in any service included but not limited to: Fitness Training, Physical Therapy, Massage, Cupping, Recovery Services, Mental Performance, Chiropractic Care, Acupuncture, Nutrition, Energy Healing, and any other Health and Wellness Service(s) offered at Thrive Proactive Health.
HEALTH INFORMATION PORTABILITY AND ACCOUNTABILITY ACT (HIPAA)
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with our services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. More information on HIPPA can be found at www.hhs.gov and our adopted HIPAA policies can be provided to you upon request. I understand that this consent shall remain in force from this time forward.
CONSENT FOR TRANSMISSION OF PROTECTED HEALTH INFORMATION BY NON-SECURE MEANS
It may become useful during the course of treatment to communicate by email, text message (e.g. “SMS”) or other electronic methods of communication. Be informed that these methods, in their typical form, are not confidential means of communication. If you use these methods to communicate, there is a reasonable chance that a third party may be able to intercept those messages. The kinds of parties that may intercept these messages include, but are not limited to: People in your home or other environments who can access your phone, computer, or other devices that you use to read and write messages, your employer, if you use your work email to communicate, third parties on the Internet such as server administrators and others who monitor Internet traffic. I consent to allow to use unsecured email and mobile phone text messaging to transmit to me the following protected health information:
- Appointment reminders, information or rescheduling needs
- Marketing offers
I have been informed of the risks, including but not limited to my confidentiality in treatment, of transmitting my protected health information by unsecured means. I understand that message & data rates may apply.
FINANCIAL AGREEMENT
In an attempt to keep our patients informed and to ensure proper reimbursement for services rendered, we ask that you carefully review the following and ask any questions you have. I understand that some of the services performed at Thrive Proactive Health are elective services and cannot not be billed to my insurance. Payments for services rendered are due in full at the time of service. I understand that Thrive Proactive Health accepts cash, check, CareCredit, and major credit cards as acceptable forms of payment for service, as well as offers various memberships and packages options to reduce financial ambiguity. Health Savings/Reimbursement accounts or Flexible Spending Accounts may be used for many of our services. More details about those can be found at: https://thrivevb.com/payment-insurance/. Before a service is performed, please consider any questions you may have for the provider, as all sales are final and nonrefundable. We are committed to client satisfaction and are available to answer any questions or concerns you may have in regards to the services we offer before purchase and before services are rendered.
With this consent, I understand that Thrive Proactive Health will pursue all means necessary to collect payment from me for my rendered services at Thrive Proactive Health and in the event that I do not pay, I approve Thrive Proactive Health to seek legal recourse to collect any and all unpaid balance(s). We do participate with certain Insurance Companies and use a Third Party Billing company called Practice Pro to bill medical insurances and collect payment for multiple disciplines. If your insurance denies billing or does not agree to pay for services rendered, based on our current standing with them, you agree to pay $129/visit.
By signing this document, you understand that medical insurances will not cover the cost of any orthotics, supplies, or any REVIVE wellness + OPTIMIZE performance services and payment of those is expected at the time of service rendered. Clients are encouraged to contact their insurance company to determine their eligibility, however we may help you verify your benefits and an Insurance Verification Form needs to be completed.
By signing this waiver, I acknowledge receipt and explanation of HIPAA, as well as agree to all of the terms and conditions stated above.