Form – The Muscle Project

We're excited to start your Project. Please let us know how to get in touch with you, or feel free to reach out to us at info@the-muscle-project.com or 703-629-1600.

TMP Health History

Step 1 of 4 - General Information

General Info
Today's Date
Date Format: MM slash DD slash YYYY
Name*
First Last
Gender
- Male
- Female
DOB
*Date of Birth
Age
Contact Info
Mailing Address
Street Address City State ZIP Code
Email
Home Phone
Work Phone
Pager/Cell
Emergency Contact Person
First Name Last Name
Phone
Emergency Contact Person Phone Number

Part 1 - Medical History (Page 2)
Please complete the following information as completely and thoroughly as possible. This is an extremely important section of this questionnaire.
5. Please provide any radiological reports you may have from x-rays or MRI’s.
Fill-in the fields with respect to the body part and your age when the event occurred.
Body Part: Head/Jaw (i.e. Clicking jaw, concussion, etc.)
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Cervical/Neck (i.e. whiplash, stiffness, etc.)
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Thoracic/ Mid back
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Lumbar/ Low back
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Ribs
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Abdomen (i.e. hernia, c-section, etc.)
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Pelvis
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Shoulder/Scapulae/Rotator cuff
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Elbow (i.e. tennis elbow)
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Knees
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
Body Part: Knees Ankles/Feet Do you wear Orthotics?
1-18 years 19-29 years 30-45 years 46-60 years 60+ years
5.1 (Optional) Upload reports
If you have a digital copy of your radiological reports, you can upload them using this button.
6. Trauma/Injury/Surgery History (Starting from your earliest memory) include even what you might consider minor, non-medically treated injuries.
7. Have you had any cosmetic/plastic surgery? Please describe below.
8. Diagnosed Diseases. Please Provide all medical reports (X-rays/MRI/CT Scan)
Orthopedic (i.e. Spinal fusion, Knee joint replacement) Initial Diagnosis Made
Metabolic (i.e. Diabetes, Hypothyroid) Initial Diagnosis Made
Neurological (i.e. Stroke, Parkinson’s) Initial Diagnosis Made
Dental Work (Braces/Night Bite Plates, Appliances) Initial Diagnosis Made
9. What is your Occupation? (Physical)
How Long Under this Stressor?
9.1 What is your Occupation? (Emotional)
How Long Under this Stressor?
10. Please prioritize the severity (#1 is the worst or greatest concern) of your current physical pain/discomfort
#1 #2 #3 #4
12. If you feel that you are experiencing unusual levels of stress in one or more of the following areas Please circle ‘Yes” if not circle “No”:
Home:
- Yes
- No
Work:
- Yes
- No
Financial:
- Yes
- No
Relational:
- Yes
- No
13. Please describe a typical day of activity for you.
Example: “My morning Starts at 6:00 am and I drink a cup of coffee and drive to work. I sit at a desk until noon and order lunch from a local restaurant. I typically work through lunch. I sit at a computer and talk on the phone and end my work day at 6pm. I drive home, pick up my kids and eat dinner around 7pm. I do house chores and am in bed by 11pm.”
14. Please describe your shoe wear. What do you wear the most throughout the week?
15. What physical activities and/or physical positions can you not perform? (I.e. kneeling down, reaching overhead)
16. What self-care strategies do you currently use to manage your own health and why? (Ice packs, stretching, acupuncture, magnets, heating pad, massage, etc.)
17. Please include any additional comments or concerns you may have?

Goal Name	1 (Far)	2	3	4	5 (Half way)	6	7	8	9	10 (Done)

TMP Health History

Step 1 of 4 - General Information

General Info

Contact Info

PART 1 – Medical History

4. Do you now have or in the past suffered from any of the following?

Part 1 - Medical History (Page 2)

5. Please provide any radiological reports you may have from x-rays or MRI’s.

12. If you feel that you are experiencing unusual levels of stress in one or more of the following areas Please circle ‘Yes” if not circle “No”:

Part 2: Fitness and Wellness

4. Please list and rate the goals for your movement/exercise program as far as how close or far you are from reaching them right now; Circle a number for each goal listed.

Please answer the following set of questions by checking "Yes" or "No"

Name of Supplement	Dosage	Why/How long have you been taking this supplement?

Orthopedic (i.e. Spinal fusion, Knee joint replacement)	Initial Diagnosis Made

Metabolic (i.e. Diabetes, Hypothyroid)	Initial Diagnosis Made

Neurological (i.e. Stroke, Parkinson’s)	Initial Diagnosis Made

Full Name	Address and Phone	Care Provided

1-18 years	19-29 years	30-45 years	46-60 years	60+ years

1-18 years	19-29 years	30-45 years	46-60 years	60+ years

1-18 years	19-29 years	30-45 years	46-60 years	60+ years