Sports Performance Patient Intake / Medical History Form - Vasta Performance Training and Physical Therapy

Patient Intake / Medical History Form

First Name
Last Name
Date of Birth
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone
Cell Phone
Email*
Emergency Contact Person
First Last
Emergency Contact Person Phone Number*
Emergency Contact Person Email*
Emergency Medical Considerations*
Please Choose Your Trainer
How did you hear about VASTA?
Who referred you to Vasta?
Which website did you learn about Vasta on?
Which friend referred you to Vasta?
Other: Please elaborate
Physical Activity Readiness Questionnaire (PAR-Q)
Please be sure to answer all questions honestly for your personal health and well being.
Physician's Name*
Physician's Phone Number*
Physician's Contact Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of last Physical Exam*
MM slash DD slash YYYY
Has a physician ever told you that you should only perform exercise prescribed by a physician?*
- Yes
- No
Do you feel chest pain when you perform physical activity?*
- Yes
- No
Do you lose your balance due to dizziness or even lose consciousness?*
- Yes
- No
Do you have a bone or joint problem that could be worsened due to a change in your physical activity?*
- Yes
- No
Please check all of the following that apply or have applied to you.*
- Male Over 45
- Hernia
- Pacemaker
- Epilepsy
- Arthritis
- Stress
- Overweight
- Chest Pain
- Smoker
- Female Over 55
- Heart Attack
- Numbness
- Diabetes Type 1
- High Cholesterol
- Obese
- Stroke
- Asthma
- Pregnant
- Heart Surgery
- Diabetes Type 2
- High Blood Pressure
- Morbidly Obese
- Dizziness or Loss of Consciousness
- Heartbeat Irregularity
- Coronary Artery Disease
- Chronic Obstructed Pulmonary Disease
- Diabetes Gestational
- Fibromyalgia
- Muscualr/Skeletal Problems
- None Apply
Are you a smoker?*
- Yes
- No
During exercise or physical activity, which of the following, if any do you experience?*
- Shortness of Breath
- Dizziness or Loss of Consciousness
- Numbness
- Chest Pain
- None of these
Any other considerations, past injuries, or surgeries that might affect your ability to perform exercise or make exercise unsafe, unwise, or dangerous; please list below:*
If you are taking any medications prescribed by a physician, please list them below.  List the name of the medication, and the condition for which you are taking it and how long you've been taking it.*
Family History
Please take a moment to reflect on your family history. Please answer the questions honestly, and to the best of your knowledge. Your family history is important information for your Trainer to know to ensure your safety during the implementation of exercise testing, programming and prescription.
Do any of the following apply to you?*
- Father, brother, or son had heart attack or died suddenly before age 55
- Mother, sister, or daughter had heart attack or died suddenly before age 65
- Immediate relative with diabetes
If you answered YES to any question or checked two or more risk factors above, you need to get a Medical Clearance Form signed and dated by your physician before you have a fitness assessment or receive exercise programming and instruction form VASTA Performance Training, Inc. Please visit for Medical Clearance Form.

If you answered NO to all questions or checked one or no risk factors above, you can be reasonably sure that it is safe for you to have a fitness assessment and begin an exercise program; however, VASTA Performance Training, Inc recommends that all beginning exercisers have a physical examination with their doctor before visiting us. When you are ready to begin, please call (802)-399-2244 or e-mail customerservice@vastasports.com to schedule an appointment.
Injury History
Please take a moment to reflect on your injury history. Please answer the questions honestly, and to the best of your knowledge. Your injury history is important information for your Coach/Trainer to know to ensure your safety during the implementation of exercise testing, programming and prescription.
Please enter injury date, then the injury and then how it happened. The more specific you are the more accurate we can be in assessing root causes and prescribing your exercise program. Example: 1/1/15, Tore ACL, playing soccer. I was landing after jumping for a head ball and my knee buckled beneath.
Injury #1 Date
MM slash DD slash YYYY
Injury #1
Injury #1 Detail
Injury #2 Date
MM slash DD slash YYYY
Injury #2
Injury #2 Detail
Injury #3 Date
MM slash DD slash YYYY
Injury #3
Injury #3 Detail
Work
Please tell us about what you do for work. Do you sit for long periods, do you take a lot of stairs, do you perform a lot of repetitive actions, do you spend a lot of time in the car? Please tell us specifics.
How many hours do you sit at work each day?
Please be accurate as this greatly influences the exercise prescription we will prescribe for cardiovascular and musculoskeletal health and longevity.
Daily work conditions and habits. Please include things like indoors, outdoors, air conditioned, high-intensity/stress, low-intensity/stress.*
Please be accurate as this greatly influences the exercise prescription we will prescribe for cardiovascular and musculoskeletal health and longevity.
Current Physical Activity and Condition Information*
Please take a moment to reflect on your current level of physical activity and condition. Answer all questions honestly, and to the best of your knowledge. The information provided will be given to your Trainer to aid with the implementation of programming, testing, and prescription.
How would you rate your current activity level?*
If you are currently active or very active, please check the types/amounts of exercise that you perform*
Cardiorespiratory/Aerobic Exercise (walking, running, skiing, biking) Frequency*
Cardiorespiratory/Aerobic Exercise (walking, running, skiing, biking) Duration*
Cardiorespiratory/Aerobic Exercise (walking, running, skiing, biking) Intensity*
Resistance/Strength (free weights, weight machines, exercise/aerobics classes) Frequency*
Resistance/Strength (free weights, weight machines, exercise/aerobics classes) Duration*
Resistance/Strength (free weights, weight machines, exercise/aerobics classes) Intensity
Flexibility/Stretching Exercises Frequency*
Flexibility/Stretching Exercises Duration
Flexibility/Stretching Exercises Intensity*
Nutrition
Current Nutrition Information
What time of day do you eat breakfast? What do you typically eat for breakfast?*
Be as specific as you can. Tell us about portion size, condiments, sauces, etc>
What do you eat for lunch? What do you typically eat for lunch?*
Be as specific as you can. Tell us about portion size, condiments, sauces, etc>
What time of day do you eat dinner? What do you typically eat for dinner?*
Be as specific as you can. Tell us about portion size, condiments, sauces, etc>
Do you eat snacks? What times of day do you have a snack? What types of foods do you eat at snack time?
Be as specific as you can. Tell us about portion size, condiments, sauces, etc>
Do you have any food allergies?
- Yes
- No
Do you have any food sensitivities?
- Yes
- No
Do you take any supplements?
- Yes
- No
Are you currently following a diet or specific nutrition strategy(s)? Examples are paleo, vegetarian, and Mediterranean.
- Yes
- No
Have you had formal nutrition education?
- Yes
- No
Have you worked with a nutrition expert, sports nutritionist or registered dietitian before?
- Yes
- No
Are you interested in nutritional programming and education?
- Yes
- No
What type of diet/nutrition strategy are you following?*
Keto, Paleo, Mediterranean, Pescatarian, Vegan, Vegetarian, etc
Do you consume alcohol?*
- Yes
- No
Goals
What are your health, fitness, activity and athletic goals?*
Goal #1: Why is this goal important to you? Or what will happen to or for you when you reach this goal?
Goal #1: What skills or abilities do you need to gain to reach this goal? Why?
Goal #1: What obstacles do you face while attempting to reach this goal? Why?
Goal #1: Who will support you in reaching this goal?
Goal #2: Why is this goal important to you? Or what will happen to or for you when you reach this goal?
Goal #2: What skills or abilities do you need to gain to reach this goal? Why?
Goal #2: What obstacles do you face while attempting to reach this goal? Why?
Goal #2: Who will support you in reaching this goal?
Goal #3: Why is this goal important to you? Or what will happen to or for you when you reach this goal?
Goal #3: What skills or abilities do you need to gain to reach this goal? Why?
Goal #3: What obstacles do you face while attempting to reach this goal? Why?
Goal #3: Who will support you in reaching this goal?
Expectations
We want to learn what you know or think about what is necessary to realize your goals
How often or frequent do you feel you should be exercising/ training to reach your goal(s)? Why?
How much time do you feel you need to commit to exercise/training to reach your goals?
How long (days, weeks, months, or years) do you think it will take to reach your goals? Why?
How many days do you feel you should take off from exercise/ training each week? Why?
Please click on each image below to indicate location(s) of PAIN.
TODAY
PRIOR TO TODAY
Please click on each image below to indicate where you feel NUMBNESS or TINGLING.
TODAY
PRIOR TO TODAY
Health or Medical Documents from Doctor
Drop files here or

Accepted file types: jpg, gif, png, pdf, doc, xls, Max. file size: 50 MB.
Please upload x-rays, blood work reports, medication prescription, physical therapy or sports medicine prescriptions or any pertinent documents related to your health that would be beneficial for your coach/trainer.
Release of Liability – (Please read before signing)
In consideration of being allowed to participate in any way in VASTA Performance Training, Inc. (VASTA) related events and activities, the undersigned acknowledges, appreciates and agrees that: 1) The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2) I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releasees or others, and assume full responsibility for my participation or my child’s participation. 3) I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest employee/ volunteer. VASTA I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release and hold harmless VASTA it’s employees, subcontractors, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (releasees), with respect to all and any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.
Signature*

Patient Intake / Medical History Form

Physical Activity Readiness Questionnaire (PAR-Q)

Family History

Injury History

Work

Nutrition

Goals

Expectations

Additional Information

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