Proellixe Client Questionnaire

The following list of contraindications is not absolute.  Some of these can be addressed with whole body vibration in conjunction with a doctor’s care.  Some absolutely should not.  If any of these conditions should occur after you begin sessions, you are responsible for letting us know.

· Pregnancy  

· Any surgeries in the last 3 months

· Car accident                         

· Ski accident                          

· Head/brain trauma                 

· Concussion

· Acute thrombosis                  

· Any history of blood clots       

· Pulmonary embolism             

· D.V.T.

· Aneurism of the aorta            

· Stent                                      

· Pins                                       

· Plates

· Poor sensitivity in feet            

· Insulin diabetes                       

· Severe diabetic nephropathy or neuropathy                   

· Epilepsy                               

· Seizures, even once                

· Parkinson’s disease

· Recent infections or fractures           

· Acute inflammation                 

· Severe migraine or history of migraines

· Retinol conditions                  

· Neurological conditions        

· Auto immune deficiency

· Heart valve disorder, serious cardiovascular disease, or congestive heart failure               

· Pacemaker or ICD

· Tumors                                 

· Discopathy                               

· Hernia                          

· Spondylolisthesis          

· Disk/back problems: _______________________                       

· Recent joint, IUD or other implant (date) _____________     

· Calculosis (stones in kidneys, urinary bladder, or gallbladder)       

· History of cancer (date): ____________

Do you have dizzy spells, severe headaches, or faint easily? ________________________

Do you have shortness of breath? ______________________________________________

Have you gained or lost weight recently? _________________________________________

Do you faint easily? __________________________________________________________

Have you ever had a serious illness or are you currently under of the care of a Physician?

Check one:

· No

· Yes, for: ___________________________________

Have you had a medical examination in the last year?  Date ___________

Has the doctor ever told you to be restrictive with any exercise or movement?  Check one:

· No

· Yes, I am not supposed to: __________________________________________

Have you taken any medicines or drugs recently?  Check one:

· No

· Yes: _____________________________________________________________

· Do they affect your motor capabilities (e.g. you shouldn’t drive)? ________________

With any exercise program you should discuss with your primary Physician. 

Information is available for you to take to your physician.  I welcome and encourage

communication with your physician in order to assure your sessions are a part of

an overall health plan that is suited to your individual needs.  Please give your

physician my business card.

Please return with your doctor's signature

X_________________________________ Date_______________

In order to recommend and provide a proper program and recommendation, it is important

to review each patient’s vital information. Please answer all of the questions outlined

below.  This information will remain confidential at all times.

Name:  ____________________________________________________________

Address: ___________________________________________________________________

                        Street                        City                                    Postal Code

Birthday: ______________________   Phone:  _________________

Whom may we thank for referring you? ________________________

What are your main concerns or objectives? ______________________________________

Start Weight _____________   Finish Weight ____________

Initial Measurements:                        

Bust              ______ ________

Hips              _______________                

Abdomen     _______ ________

Thigh           _______________              

Goal area     _______________       

To the best of my knowledge, the above information is correct.  I accept full responsibility

for checking or failing to check with my physician, and therefore do not hold

Ascending Energy nor its owner/s responsible for any complications that arise.

_____________________________                                                         ____________

Signature                                                                            Date