Assessment Form

Medical Information in Case of Emergency

The information in this form will be kept confidential except as required by law. Your written permission will be required to release any information. It is important to be accurate so that we can ensure it is safe for you for receive treatment or engage in physical activity. If your health status or contact information changes in the future, please let us know.

Date*

Name*

First Last

Gender

Male
Female

Date of Birth*

You are interested in?*

The Burdenko Method
Pain Relief, Therapy, and Rehabilitation
General Conditioning
Weight Loss
Sports Specific Training
Weight Lifting, Olympic Lifting, Strength Training

Mailing Address

Street Address City Postal Code

Email adress*

Home Phone*

Work Phone

Occupation/Work

Cell Phone

Emergency Contact Person

Phone Number

Relationship

What is your primary concern, goal?

Do you have any allergies?

Yes
No

If you have allergies, please list them:

Epipen?

Yes
No

Do you have any family history of:

Cancer
Diabetes
Heart Disease
Hypertension
Stroke

Which relative had cancer?

Which relative had diabetes?

Which relative had heart disease?

Which relative had hypertension?

Which relative had a stroke?

Check the boxes below that pertain to you either now or in the past:

What type of cancer?

When did you get diagnosed with cancer?

Did you or are you undergoing treatment?

Yes
No

Are you still being followed by a doctor?

Yes
No

Are there any contraindications to you undertaking a rehabilitation, conditioning, or training program due to your cancer?

Yes
No

Please describe:

Are you being followed by a doctor?

Yes
No

What is/was the diagnosis?

What are your limitations due to your neurological issue?

Are there any contraindications to you undertaking a rehabilitation, conditioning, or training program due to your neurological issue?

Yes
No

Please describe:

What sports or physical activities to you partake in?

What are your short-term health and fitness goals?

Koom: Client Initial Assessment Form