Emergency Contact Phone Number

Primary City of Residence

How did you hear about us?

1. Primary Health & Performance Goals

What are your top priorities for this program? (Check all that apply)

What specific outcomes do you want to achieve in the next 30-90 days?

Have you worked with a manual therapist, movement coach, or performance specialist before?

Tell us about your past experiences. What has/hasn't worked well.

2. Current Symptoms & Medical History

Do you currently experience any of the following? (Check all that apply)

Are you currently under the care of a healthcare provider for any of these conditions?

Diagnosed medical conditions?

Recent Surgeries or Hospitalizations?

Past physical trauma or chronic pain patterns effecting movement?

Current prescribed medications?

Recent bloodwork or functional lab tests available?

Do you use any of the following regularly? (Check all that apply)

What are your primary reasons for using supplements?

If other please specify:

How consistent are you with you supplementation routine?

How many hours of sleep do you typically get?

How is your sleep quality?

Sleep struggles? (Check all that apply)

Falling Asleep

Staying asleep

Waking up frequently

Waking up tired despite enough hours

Do you snore?

Have you ever participated in a sleep study?

Use of sleep aids? (medications, supplements, night guard, CPAP machine)

Do you track your sleep with a device?

How stable is your energy throughout the day?

Do you feel well rested upon waking?

5. Nutrition & Digestive Health

How would you describe your current nutrition/dietary approach?

Food Allergies/intolerances?

How many meals per day?

4 or more

Do you consume alcohol?

Never

1-2x/month

(1-2x/week)

(3+ per week)

Use of recreational drugs or cannabis? (If yes, please list:)

6. Movement & Exercise History

How often do you exercise per week?

Past injuries still impacting you on a regular basis?

Do you currently have any movement, posture, or pain-related challenges?

What does a typical week of activity look like for you?

7. Stress & Nervous System Health

Rate your current stress levels:

Do you practice any stress-management techniques? (Check all that apply)

Breathwork

Meditation

Cold exposure (ice baths, cryotherapy)

Heat exposure (sauna, baths, etc.)

Other (Pease specify):

Primary sources of stress? (Check all that apply)

Work

Relationships

Health concerns

Financial stress

Do you notice patterns like:

Muscle clenching / jaw tension

Holding breath / shallow breathing

Difficulty unwinding/relaxing

Irritability / emotional sensitivity

Symptoms of nervous system dysregulation (anxiety, fatigue, burnout, mood swings)?

Anything else I should know about your health, lifestyle, or fitness goals?

Client Agreement & Consent

All information shared with Structural Therapeutics is strictly confidential. This includes your personal, medical, and movement history, as well as anything discussed during sessions. Your information will never be shared without your written consent, except as required by law or in cases of potential harm to yourself or others.

I confirm that the information provided is accurate. I understand that Structural Therapeutics provides holistic health services and does not diagnose or treat medical conditions.

3. Supplementation

4. Sleep & Recovery

7. Stress & Nervous System Health

Client Agreement & Consent