Client Intake Questionnaire

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                    POSTUROPRO — CLIENT INTAKE QUESTIONNAIRE
                        Zone-Based Musculoskeletal History
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CLIENT INFORMATION
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Full Name: _______________________________________________
Date of Birth: ___________________________________________
Email: __________________________________________________
Phone: __________________________________________________
Date Completed: __________________________________________

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SECTION 1 — CURRENT CONDITIONS & CHIEF COMPLAINT
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1. What is the main reason you are seeking movement assessment today?
   ___________________________________________________________________
   ___________________________________________________________________

2. How long have you had this condition or concern?
   ___________________________________________________________________

3. On a scale of 0–10, what is your average daily discomfort or limitation level?
   (0 = none, 10 = severe)   Rating: _______

4. Does your discomfort vary during the day? When is it worst?
   ___________________________________________________________________

5. Have you had any recent imaging (X-ray, MRI, CT scan)? If yes, what were the findings?
   ___________________________________________________________________
   ___________________________________________________________________

6. Have you had surgery or significant injuries in the past 5 years?
   ___________________________________________________________________
   ___________________________________________________________________

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SECTION 2 — GOALS
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7. What are your top 3 movement or health goals?
   1. ________________________________________________________________
   2. ________________________________________________________________
   3. ________________________________________________________________

8. What activities do you want to be able to do that are currently limited?
   ___________________________________________________________________
   ___________________________________________________________________

9. What does success look like for you after working together?
   ___________________________________________________________________
   ___________________________________________________________________

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SECTION 3 — GENERAL MEDICAL HISTORY
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10. Do you have any diagnosed medical conditions? (e.g. diabetes, osteoporosis,
    heart condition, neurological condition, autoimmune disease, cancer history)
    ___________________________________________________________________
    ___________________________________________________________________

11. Are you currently taking any medications? If yes, please list:
    ___________________________________________________________________
    ___________________________________________________________________

12. Do you have any known allergies?
    ___________________________________________________________________

13. Are you currently pregnant or postpartum (within 12 months)?
    ___________________________________________________________________

14. Do you have a history of falls in the past 12 months? If yes, how many?
    ___________________________________________________________________

15. Rate your general energy levels on a typical day (0–10): _______

16. How would you describe your sleep quality? (Poor / Fair / Good / Excellent)
    ___________________________________________________________________

17. Rate your stress levels on a typical day (0–10): _______

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ZONE 1 — FEET, ANKLES, KNEES & HIPS
Load Entry & Ground Interaction
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FEET & TOES
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18. Do you experience pain, stiffness, or discomfort in your feet?
    □ No   □ Yes — describe: _________________________________________

19. Which foot/feet are affected?   □ Right   □ Left   □ Both

20. Do you have any of the following? (check all that apply)
    □ Plantar fasciitis or heel pain
    □ Flat feet (overpronation)
    □ High arches (supination)
    □ Bunions (big toe deviation)
    □ Hammer toes or toe stiffness
    □ Numbness or tingling in the toes
    □ Calluses or pressure areas on specific areas of the foot
    □ None of the above

21. Does your foot pain change with footwear? Describe:
    ___________________________________________________________________

ANKLES
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22. Do you experience pain, stiffness, or clicking in your ankles?
    □ No   □ Yes — describe: _________________________________________

23. Have you ever sprained an ankle?   □ No   □ Yes — which side and when?
    ___________________________________________________________________

24. Do you notice limited range of motion bending your ankle upward (squatting)?
    □ No   □ Yes — □ Right   □ Left   □ Both

25. Do your ankles swell? If yes, when and how often?
    ___________________________________________________________________

LOWER LEG (Shins & Calves)
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26. Do you experience tightness, cramping, or pain in your calves or shins?
    □ No   □ Yes — describe: _________________________________________

27. Have you ever had shin splints or calf tears?
    □ No   □ Yes — describe: _________________________________________

KNEES
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28. Do you experience pain, stiffness, swelling, or clicking in your knees?
    □ No   □ Yes — describe: _________________________________________

29. Which knee?   □ Right   □ Left   □ Both

30. Do any of the following apply? (check all that apply)
    □ Pain going up or down stairs
    □ Pain kneeling or squatting
    □ Knee buckles or gives way
    □ Knee locks or catches
    □ Diagnosed osteoarthritis of the knee
    □ Previous knee surgery (meniscus, ACL, replacement, etc.)
    □ None of the above

31. Describe your knee surgery or diagnosis if applicable:
    ___________________________________________________________________

THIGHS (Quadriceps & Hamstrings)
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32. Do you experience tightness, pain, or weakness in your thighs?
    □ No   □ Yes — describe: _________________________________________

33. Do you have a history of hamstring or quadriceps strain or tear?
    □ No   □ Yes — describe: _________________________________________

HIPS
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34. Do you experience pain, stiffness, clicking, or pinching in your hips?
    □ No   □ Yes — describe: _________________________________________

35. Which hip?   □ Right   □ Left   □ Both

36. Do any of the following apply? (check all that apply)
    □ Pain at the front of the hip (flexion/sitting)
    □ Pain at the outer hip or side (lateral hip)
    □ Pain deep in the hip (groin area)
    □ Hip bursitis (diagnosed)
    □ Hip labral tear (diagnosed)
    □ Hip impingement / FAI (diagnosed)
    □ Hip replacement (total or partial)
    □ Avascular necrosis
    □ None of the above

37. Describe your hip diagnosis or surgery if applicable:
    ___________________________________________________________________

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ZONE 2 — PELVIS, SACRUM & LUMBAR SPINE
Load Transfer & Central Stability
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SACROILIAC JOINT (SI Joint)
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38. Do you experience pain or stiffness at the base of your spine / tailbone area?
    □ No   □ Yes — describe: _________________________________________

39. Which side?   □ Right   □ Left   □ Both   □ Central

40. Does SI joint pain refer into the buttock or down the leg?
    □ No   □ Yes — describe: _________________________________________

PELVIS & GLUTEAL REGION
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41. Do you experience pain, tightness, or numbness in your buttocks or gluteal region?
    □ No   □ Yes — describe: _________________________________________

42. Have you been told you have piriformis syndrome or sciatic nerve irritation?
    □ No   □ Yes — describe: _________________________________________

43. Do you have difficulty engaging or feeling your gluteal muscles during activity?
    □ No   □ Yes

LUMBAR SPINE (Lower Back)
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44. Do you experience pain, stiffness, or discomfort in your lower back?
    □ No   □ Yes — describe: _________________________________________

45. Does your lower back pain radiate or refer anywhere? If yes, describe:
    ___________________________________________________________________

46. Do any of the following apply? (check all that apply)
    □ Disc herniation / bulge (diagnosed)
    □ Degenerative disc disease
    □ Lumbar spinal stenosis
    □ Spondylolisthesis (vertebral slippage)
    □ Scoliosis (lumbar curve)
    □ Lumbar fusion surgery
    □ Lumbar pain when sitting for extended periods
    □ Lumbar pain when standing for extended periods
    □ Lumbar pain when walking
    □ None of the above

47. Describe your lumbar diagnosis or surgery if applicable:
    ___________________________________________________________________

48. Do you have difficulty with bowel or bladder control related to your back?
    (This is relevant for determining nerve involvement)
    □ No   □ Yes — have you reported this to your physician?  □ Yes  □ No

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ZONE 3 — RIB CAGE, THORACIC SPINE & SHOULDER COMPLEX
Load Distribution, Rotation & Breath
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MID-BACK & THORACIC SPINE
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49. Do you experience pain, stiffness, or discomfort in your mid-back or between
    the shoulder blades?
    □ No   □ Yes — describe: _________________________________________

50. Do any of the following apply? (check all that apply)
    □ Thoracic kyphosis ("rounded upper back")
    □ Scoliosis (thoracic curve — diagnosed)
    □ Thoracic disc herniation (diagnosed)
    □ Rib pain or costochondritis
    □ Pain with deep breathing or coughing
    □ Thoracic fusion or surgery
    □ None of the above

RIB CAGE & BREATHING
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51. Do you have any difficulty breathing deeply or expanding your chest fully?
    □ No   □ Yes — describe: _________________________________________

52. Do you have a history of any respiratory conditions? (asthma, COPD, etc.)
    □ No   □ Yes — describe: _________________________________________

53. Are you generally aware of your breathing during daily activity?
    □ No   □ Yes — describe what you notice: __________________________

SHOULDERS
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54. Do you experience pain, stiffness, clicking, or weakness in your shoulders?
    □ No   □ Yes — describe: _________________________________________

55. Which shoulder?   □ Right   □ Left   □ Both

56. Do any of the following apply? (check all that apply)
    □ Rotator cuff tear or impingement (diagnosed)
    □ Frozen shoulder / adhesive capsulitis
    □ Shoulder instability or dislocation history
    □ AC joint injury (top of shoulder)
    □ Shoulder replacement or surgery
    □ Pain reaching overhead
    □ Pain reaching behind the back
    □ Shoulder blade winging or instability
    □ None of the above

57. Describe your shoulder diagnosis or surgery if applicable:
    ___________________________________________________________________

ELBOWS
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58. Do you experience pain, stiffness, or clicking in your elbows?
    □ No   □ Yes — □ Right   □ Left   □ Both

59. Do any of the following apply? (check all that apply)
    □ Tennis elbow (lateral epicondylitis)
    □ Golfer's elbow (medial epicondylitis)
    □ Ulnar nerve irritation (funny bone tingling)
    □ Elbow fracture or surgery history
    □ None of the above

WRISTS & HANDS
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60. Do you experience pain, stiffness, numbness, or tingling in your wrists or hands?
    □ No   □ Yes — describe: _________________________________________

61. Do any of the following apply? (check all that apply)
    □ Carpal tunnel syndrome
    □ Wrist fracture history
    □ Arthritis in the hands or fingers
    □ Trigger finger
    □ None of the above

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ZONE 4 — CERVICAL SPINE, JAW, HEAD & NERVOUS SYSTEM
Orientation, Vigilance & Autonomic Regulation
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CERVICAL SPINE (Neck)
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62. Do you experience pain, stiffness, or limited range of motion in your neck?
    □ No   □ Yes — describe: _________________________________________

63. Does your neck pain refer pain, numbness, or tingling into your arms or hands?
    □ No   □ Yes — describe: _________________________________________

64. Do any of the following apply? (check all that apply)
    □ Cervical disc herniation or degeneration (diagnosed)
    □ Cervical spinal stenosis
    □ Cervical fusion or surgery
    □ Whiplash history (motor vehicle or sports injury)
    □ Forward head posture (you've been told about this or noticed yourself)
    □ Neck stiffness upon waking
    □ None of the above

65. Describe your cervical diagnosis or surgery if applicable:
    ___________________________________________________________________

JAW & FACE
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66. Do you experience pain, clicking, locking, or tension in your jaw?
    □ No   □ Yes — describe: _________________________________________

67. Have you been diagnosed with TMJ disorder (temporomandibular joint)?
    □ No   □ Yes — describe treatment received: ________________________

68. Do you clench or grind your teeth (bruxism)?
    □ No   □ Yes — □ During the day   □ At night   □ Both

69. Do you experience regular headaches? If yes, describe location and frequency:
    ___________________________________________________________________

70. Do you experience migraines?   □ No   □ Yes — frequency: ____________

EYES & VESTIBULAR (Balance System)
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71. Do you experience dizziness, vertigo, or balance problems?
    □ No   □ Yes — describe: _________________________________________

72. Do you have any visual problems that affect your movement or balance?
    □ No   □ Yes — describe: _________________________________________

73. Have you had any concussions or head injuries?
    □ No   □ Yes — how many, and when was the most recent? ______________

NERVOUS SYSTEM & ANS
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74. Do you experience any of the following regularly? (check all that apply)
    □ Chronic fatigue or exhaustion
    □ Difficulty recovering after exercise or activity
    □ Heightened sensitivity to touch, sound, or light
    □ Chronic widespread pain (fibromyalgia diagnosis or similar)
    □ Anxiety or a feeling of being "on guard" most of the time
    □ Feeling "shut down," disconnected, or emotionally flat
    □ Difficulty relaxing muscles even when resting
    □ Chronic gut issues (IBS, bloating, digestive sensitivity)
    □ None of the above

75. On a scale of 0–10, how would you rate your body's general ability to
    RELAX and let go of tension when you want it to?
    (0 = cannot relax at all, 10 = fully relaxed at will)   Rating: _______

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SECTION 5 — MOVEMENT HISTORY & LIFESTYLE
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76. What types of exercise or movement do you currently do regularly?
    ___________________________________________________________________

77. How many hours per day do you spend seated (desk, driving, screen time)?
    □ Less than 2 hrs   □ 2–4 hrs   □ 4–8 hrs   □ More than 8 hrs

78. What is your occupation and does it involve repetitive movement or postures?
    ___________________________________________________________________

79. Do you have a history of competitive sport or intensive athletic training?
    □ No   □ Yes — describe: _________________________________________

80. Have you previously worked with a physical therapist, chiropractor, or
    movement specialist? If yes, what was helpful?
    ___________________________________________________________________
    ___________________________________________________________________

81. Is there anything else you would like your practitioner to know before
    your first session?
    ___________________________________________________________________
    ___________________________________________________________________
    ___________________________________________________________________

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Thank you for completing this intake form.
Please return to your practitioner prior to your first appointment.
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