Digital Intake

Step 1 of 5

Hi open mind, Ready to hit the road? Please fill out the digital intake form and start off with your assessment. This will save us time so that we can use our time together optimally. After completion I will contact you asap to make an appointment. Good to know: although I’m a professional certified in many ways (If you want to see my full CV, feel free to visit my LinkedIn page.), I’m not a physiotherapist. My work with Movere Magis is specifically tailored to the teachings & philosophy of Anatomy in Motion.

BASIC INFORMATION

Your name
Billing information, if you would like an invoice: How did you hear about Movere Magis? Do you wish to work online or in person? OnlineIn-personI'm open to both

YOUR GOAL

1. What would you like to achieve? 2. What is the reason you would like to start now and not sooner or later? 3. What do you need from me to get there?

YOUR LIFESTYLE AND HEALTH

1. What is your current occupation? 2. Does your job require extended periods of sitting? 3. Does your occupation require extended periods of repetitive movements? (If yes, explain.) 4. Does your occupation cause you anxiety (mental stress)? 5. Do you partake in any recreational activities (running, tennis, dancing, etc.)? (If yes, please explain.) 6. Do you have any hobbies (reading, gardening, working on cars, etc.)? (If yes, please explain.) 7. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? (If yes, please explain.) 8. Do you have a bone or joint problem that could be made worse by a change in your physical activity? (If yes, please explain.) 9. Are you currently taking any medication? (If yes, please explain.) 10. How would you rate your own physical fitness on a scale of 0-10? (10 = best shape of my life) 11. How would you rate your own eating and drinking habits on a scale of 0-10? (10 = as far as what I know about eating and drinking healthily, I’m doing really well) 12. How would you rate your current level of stress on a scale of 0-10? (0 = no stress) 13. How would you rate your quality of sleep on a scale of 0-10? (10 = I sleep like a baby) 14. On an average night, do you sleep long enough in terms of what you consider to be your own optimal amount of sleep? [cf7mls_step cf7mls_step-1 "Next" "Step 1"] [cf7mls_step cf7mls_step-2 "Back" "Next" "Step 3"]

Step 3 of 5

INJURY HISTORY

“You are, today, the sum of all physical experiences which have taken place in your everyday life” - Gary Ward –

The goal of this exercise is to get as clear a picture as possible of whatever your body has been through. From birth until now. Nothing is irrelevant. E.g., hip problems as a baby, a hard knock on the head, broken bones, surgeries … This is not an easy exercise. Take your time. Probably you will remember new things after you have already sent this to me. If so, just mail the new recollections afterwards. No problem.

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FOOT PRESSURE ZONES

(optional)

Your foot pressure zones can help us determine your ‘Anatomy in Motion’. Observing changes in your foot pressure is synonymous with observing postural and structural changes. In our first session. we will use a force plate, so no need to worry if this exercise is difficult. However, stand with your feet hip-width apart and take a moment to check in with your feet: Check the weight distribution between your left and right foot. Check the weight distribution in each foot between your forefoot and your heel. Check to see if you have more pressure in one forefoot and the opposite heel and vice versa. Want to give it a try? yesskip

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Step 5 of 5

FILM YOUR GAIT

(optional)

Instructions: - Clothes: barefoot, shorts and a t-shirt (different colour then the shorts). - Set up your camera so that the whole body will be on camera when you walk. Distance = ± 10m - Walk away and toward the camera, 2 times. Don’t worry about the quality of the movie or how you think you should walk. Just walk. - If possible, you can also film yourself when you walk past the camera (side view), 2 times. - Send it using WhatsApp to 0032 479 / 38 38 84

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