HELEN'S DETAILS

Last update: ____________________ As you adapt to new fitness standards, your goals and needs might need to be modified.

We'll be completing this questionnaire next time we catch up: 

  • Contactdetails:   ____________________
  • Date of Birth:    ___________________
  • Clinical incidents: 
  • Contraindications: Precaution with external resistance overhead due to shoulder impingement. Also, precaution needed at lumbar level, which needs optimal strengthening (torso musculature in general) 
  • Occupation: 
  • Hours of sleep at night:
  • Daily water consumption:
  • CHEK Holistic Assessment: Pending 
  • Description of a typical day in terms of mobility: (important info to address occupational health and safety) _____________________________ __________ _____________________ _____________________ __________________________ ______________________________
  • Fitness Goals: ___________________________________________________ ___________________________________ ______________________ ___________________________________ ________________________ ___________________________
  • Fitness needs: Improve motion patterns, general motor control, strength endurance, recover hip mobility, enhance ankle mobility, avoid postural compensation, strengthening stabiliser muscles in both knees, Create strategies to reduce injury.
  • Conditioning Level: Foundation 

Orthopaedic Profile (Pending)

Conventions:  The "√" sign means optimal condition. The "∆" implies current functional impingement. The "∑" figure implies structural impingement. 

Therapeutic considerations:

  • Left Ankle:  √
  • Right Ankle: √
  • Left Knee: √
  • Right Knee: √
  • Left Hip: √
  • Right Hip: √
  • Lumbar Spine: √
  • Thoracic Spine:
  • Cervical Spine: √
  • Left Glenohumeral: √
  • Right Glenohumeral: √
  • Left Scapulae: √
  • Right Scapula: √
  • Left Elbow: √
  • Right Elbow: √
  • Left wrist: √
  • Right Wrist: √

Neuromuscular imbalances:

  • Left Calf:  √
  • Right Calf: √
  • Left Quadriceps: √
  • Right Right Quadriceps: √
  • Left Hamstring: √
  • Right Hamstring: √
  • Lumbar Region: √
  • Thoracic Region: √
  • Cervical Region: √
  • Left Pec-Major: √
  • Right Pec Major: √
  • Left Rotator Cuff : √
  • Right Rotator Cuff: √
  • Left bicep-triceps: √
  • Right biceps-triceps: √
  • Left forearm/grip: √
  • Right forearm/grip: √

Main Priorities:

  • _____________
  • ______________
  • _______________
  • ___________________