ATHLETE INTAKE
Welcome to Functional Innovative Therapeutics aka. FIT. Please fill-out the following form as
complete as possible, circling a response where necessary. Accurate demographic information is
important to ensure high-quality care, and effective communication. If your demographic information
changes, please let us know. All demographic information is strictly confidential except as required or
allowed by law.
Patient Demographic Information
Last Name:___________________First Name: _______________ Gender: F M T
DOB: (day, month, year) ___/___/_______ Age: ______
Marrital Status: single common-law married seperated divorced widowed
Number of children: ________
Address:_____________________________________ Apt # _______ City:
_______________________Postal Code: __________________
Telephone: (home) ______ - ______ - ________ (mobile) ______ - ______ - ________
Email 1: ____________________________2: _________________________
Occupation: ___________________________________________Employed: Full Time Part Time
Employer: ________________________________(work) ______ - ______ - ________ Ext: ______
Emergency Contact
Last Name:__________________ First Name: ______________ Relationship: _________________
Telephone #1: ______ - ______ - ________ #2 ______ - ______ - ________
Family Physician
Name: _________________________________________Telephone: ______ - ______ - ________
Referal Source:
□ Medical Referral Dr. Name: ____________________ Telephone: ______ - ______ - ________
Address: _____________________ Fax: ______ - ______ - ________
City: _____________________________Postal Code: __________________
□ WSIB
Claim Number:
□ MVA
Claim Number:
□ Referral (Family or Friend) Name: ________________________________________________
□ Walk in or from the gym
□ Other: _______________________________________________________________________
A Few Questions
▪ May we give you reminder calls?
▪ May we leave you phone messages?
▪ Would you like to be added to our email list for our
newsletter and information about upcoming events?
YN
YN
YN
Please Continue

HEALTH HISTORY FORM
For your information:
An accurate health history is important to ensure that it is safe for you to receive treatment. If your health status changes in the
future, please let us know. All information for treatment is confidential, except as required or allowed by law or except to facilitate diagnosis (assessment) or treatment. You will be asked to provide written authorization for release of any information.
Name:______________________________________________ Date: ________________________
Primary Complaint
Description
i.e. Chronic low back pain
When did it start?
10 years ago
How did it happen?
I strained my back playing golf
Health History: Please circle all current conditions and x any past condition. Indicate the diagnosis in the space
Respiratory
□ chronic cough
□ shortness of breath
□ bronchitis
□ asthma
□ emphysema
□ Frequent colds (#/ year _____________)
Cardiovascular
□ High blood pressure or hypertension
□ low blood pressure
□ Heart attack (when:________________)
□ Stroke (when:____________________)
□ chest pain / angina □
difficulty breathing
□ pacemaker
□ phlebitis
□ vascular disease __________________
Other Conditions
□ osteoporosis
□ prolonged steroid use
□ Inflammatory disease _______________
□ collagen disease __________________
□ diabetes (onset:___________________
□ allergies
□ cancer or tumors _________________
□ arthritis
□ sleeping disorder __________________
Infection
□ hepatitis
□ skin conditions
□ TB
□ HIV / AIDS
□ STD (what:_______________________)
(when:______________________)
Skin Condition
Symptoms
□ Skin condition _____________________ □ loss of sensation (where:___________)
□ fatigue / tiredness
□ nausea
Genitourinary
□ constipation
□ painful urination
□ unusual colour / odor of urine
□ diarrhea
□ loss of bladder control
□ rapid weight loss □
□ painful sex
appetite changes
□ loss of mental concentration
□ Leg pain / weakness / tingling
□ Arm pain / weakness / tingling
Head/Neck
□ Headaches
□ Head injury
□ Whiplash
□ Vision problems
□ ear problems
□ concussion
□ Dizziness
□ oral or dental problems or injuries
Soft Tissue / Joint Discomfort
□ neck __________________________
□ low back _______________________
□ mid back _______________________
□ upper back ______________________
□ shoulder _______________________
□ arms __________________________
□ legs ___________________________
□ hands _________________________
□ Feet ___________________________
Lifestyle
□ smoking (cig / day _______________
□ alcohol (drinks / week ____________
□ exercise (times / week____________
Other medical conditions (e.g. digestive conditions, gynaelogical conditions, hemophilia, etc.)
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
Surgeries and Medical Procedures:
List all past surgeries or medical procedures in the space provided
When
Procedure
Purpose
i.e. dec 93
right knee menisectomy
Medication:
If you have an up-to-date list of medication you are currently taking, please hand-in this list with the intake and skip this step
Medication
Purpose
Amount
Duration
i.e. vioxx
anti-inflammatory
10 mg 3 x day
2 weeks
Of Special Note: (presence of internal pins, wires, artificial joints, special equipment):
________________________________________________________________________________
________________________________________________________________________________
Present involvement in other Health Care:
YES
NO (please circle)
If yes, please specify:_______________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Patient's Signature: _________________________ Date _________ Reviewed by:__________________
PAR-Q FORM
Please mark YES or No to the following:
YES
NO
Has your doctor ever said that you have a heart condition and recommended
only medically supervised physical activity?
____
____
Do you frequently have pains in your chest when you perform physical activity?
____
____
Have you had chest pain when you were not doing physical activity?
____
____
Do you lose your balance due to dizziness or do you ever lose consciousness?
____
____
Do you have a bone, joint or any other health problem that causes you pain or
limitations that must be addressed when developing an exercise program
(i.e. diabetes, osteoporosis, high blood pressure, high cholesterol, arthritis,
anorexia, bulimia, anemia, epilepsy, respiratory ailments, back problems, etc.)? ____
____
Are you pregnant now or have you given birth within the last 6 months?
____
____
Have you had a recent surgery?
____
____
If you have marked YES to any of the above, please elaborate below:
_____________________________________________________________________________
_____________________________________________________________________________
Do you have any chronic illness or physical limitations such as Asthma, diabetes? Yes/No
_____________________________________________________________________________
Do you have any injuries or orthopedic problems such as bursitis, bad knees, back, shoulder, wrist or neck
issues ? YES/ NO Please specify ___________________________________________________
Do you take any medications, either prescription or non-prescription, on a regular basis? Yes/No
What is the medication for?_______________________________________________________
How does this medication affect your ability to exercise or achieve your fitness goals?
_____________________________________________________________________________
Lifestyle Related Questions:
1) Do you smoke?
YES
NO
If yes, how many?__________
2) Do you drink alcohol? YES
NO
If yes, how many glasses per week?__________
3) How many hours do you regularly sleep at night?
4) Describe your job:  Sedentary
5) Does your job require travel? YES
 Active
___________
 Physically Demanding
NO
6) On a scale of 1-10, how would you rate your stress level (1=very low 10=very high)? ______
7) List your 3 biggest sources of stress:
a. _______________________ b. _______________________ c._______________________
8) Is anyone in your family overweight? Mother
9) Were you overweight as a child?
YES NO
Father
Sibling
Grandparent
If yes, at what age(s)?______________
Functional Innovative Therapeutics 300 Campbell Ave, Suite 208 Toronto, ON M6P 3V6
T: 416.628.4333 F: 416.352.1268 www.fitstoronto.com email: info@fitstoronto.com
2011 FITS Alpine Athletic Development Program
FITS is the leader in athletic development, where our athletic development program not only
helps develop athleticism but more importantly helps prevent injury and develops physical
literacy for lifelong healthy active living.
Program Dates: Monday to Thursday (Choose dates that fit into your schedule)
Program Time: 6:00 – 7:30
Periods:
Spring: May 9 – June 30, 2010 (8 Weeks)
Summer: July 5 – September 1, 2010 (9 Weeks)
Fall: September 12 – December 1, 2010 (12 Weeks)
FITS has secured a dedicated time slot the Athletic Development program for exclusive
use of the facility to foster a highly motivating and competitive training environment with
expert strength and conditioning and health-care supervision. All athletes are expected
to be dedicated to the program without exception.
Program rates are non-negotiable except for medical reasons which will follow a prorated schedule or for very special schedule needs. Payments are expected based on
the following dates at the following percentages. If you have questions please contact
Dr. Thomas Lam at 416.628.4333 or via email thomaslam@fitstoronto.com
2011 Special FITS Dryland
Program
Duration
Cost
(Add
HST)
Cost per Payment due dates and
session Percentage
A
Complete 2011 Alpine
Athletic Development
Dryland Program
Spring, Summer
and Fall Session
2100
25
B
Spring and Fall Session
Spring and Fall
1700
28
C
Spring Session or
Summer Session
individually
Spring Session
OR
Summer Session
D
Fall Session
Fall Session
800
1000
33
33
$1102.50 (50%) May 9, 2011
$1102.50 (50%) on Aug 8,
2011
$892.50 (50%) on May 9,
2011
$892.50 (50%) on Sept 12,
2011
$420 (50%) on May 9, 2011
$420 (50%) on Sept 12, 2011
$525 (50%) on Sept 12, 2011
$525 (50%) on Oct 17, 2011
Functional Innovative Therapeutics 300 Campbell Ave, Suite 208 Toronto, ON M6P 3V6
T: 416.628.4333 F: 416.352.1268 www.fitstoronto.com email: info@fitstoronto.com
Thanks for making FITS Alpine Athletic Development Program Successful.
Simply circle the Payment Schedule that applies to your athlete and use
either payment option A or B.
Athlete Name:
____________________________________________
Payment Options:
A: CREDIT CARD: The credit card will be left on file and will be billed according the schedule
listed above
Name on Credit Card: ________________________________________________
Credit Card Number: _________________________________________________
SVC (Security Verification Code): ________________________________________
last three digits on the back of the credit card:
Expiry Date: _____/______
B: CHEQUES: Please post-date the cheques according to the schedule below
Cheques payable to:
Functional Innovative Therapeutics
300 Campbell Ave, Suite 208
Toronto, Ontario
M6P 3V6
Payment Schedule:
2011 Special FITS Dryland
Program
Duration
Cost
(Add HST)
Cost
per
session
Payment due dates and
Percentage
A
Complete 2009 Alpine
Athletic Development
Dryland Program
Spring, Summer and
Fall Session
2100
25
$1102.50 (50%) May 9, 2011
$1102.50 (50%) on Aug 8, 2011
B
Spring and Fall Session
Spring and Fall
1700
28
$892.50 (50%) on May 9, 2011
$892.50 (50%) on Sept 12, 2011
C
Spring Session or Summer
Session individually
Spring Session
OR
Summer Session
33
$420 (50%) on May 9, 2011
$420 (50%) on Sept 12, 2011
D
Fall Session
Fall Session
33
$525 (50%) on Sept 12, 2011
$525 (50%) on Oct 17, 2011
800
1000
Thank-you for your business
Functional Innovative Therapeutics 300 Campbell Ave, Suite 208 Toronto, ON M6P 3V6
T: 416.628.4333 F: 416.352.1268 www.fitstoronto.com email: info@fitstoronto.com