Intake Form

First name

Last name

Birthday

Month

Day

Year

Phone

Email

Address

Emergency Contact Name and Number

Sex assigned at birth

Male

Female

Prefer not to answer

HEALTH HISTORY: Have you had any of the following?

Provide relevant details for any condition selected above, including current status and precautions.

Select any that currently apply

Allergies:List all medication, food, latex, adhesive, or other allergies and describe the reaction. Include whether you carry epinephrine.

List current prescription medications, over-the-counter medications, and supplements.

List significant surgeries, hospitalizations, or medical procedures and approximate dates.

List any recent imaging, laboratory testing, or other relevant findings.

Are you currently under the care of another healthcare professional for a condition that may affect treatment or exercise? If yes, explain.

Current safety screen: Are you currently experiencing any of the following?

Current concern: What is the primary body area or concern you want addressed?

When did it begin, and did it start suddenly or gradually?

Describe the symptoms and exact location.

What activities or movements trigger or relieve the symptoms?

What have you tried, and what was the response?

Is it related to climbing or training?

Yes

No

Unsure

How does it affect climbing, training, work, sleep, or daily activities?

Do you have another body area or concern you want addressed? If yes, briefly describe it.

Relevant injury history: List prior injuries that caused you to stop or modify climbing, training, work, or daily activity, or that required professional care. Include the body area, approximate date, and current status.

What would make this consultation successful for you?

Current climbing and training volume: Total years climbing and years climbing consistently without a long break

Current climbing activities

During a typical week, how many days do you climb and how long is each session?

Describe your current climbing intensity. Include usual grades, hardest recent grades or projects, and how hard sessions feel.

Describe other weekly training, including strength, cardiovascular training, mobility work, and recovery days.

Do you use a wearable or app to track training? If yes, list the device or app and what you track.

I confirm that the information provided is accurate and complete to the best of my knowledge. I will inform Beta for Your Body of material changes in my health, medications, or symptoms. Client Signature

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