Medical Questionnaire ⁄ Integra

What to expect

Welcome to Integra!

You are booked in for an initial consultation, here’s what to expect.

Your initial session is designed to lay the groundwork for getting the best out of your time with us. This includes:

Exploring your goals, needs, and expectations
Mapping out your joint & muscle function and movement
Start to develop a pathway, including exercise, nutrition, coaching, and lifestyle strategies to help you achieve your bravest goals

Please fill out for the form below. We are looking forward to getting started!

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ADDRESS

Street Address City ZIP / Postal Code Country

Email Address(Required)

Telephone Number(Required)

DATE OF BIRTH

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Age

Medical Questionnaire

Has your doctor ever said your blood pressure was too high or too low?(Required)

Yes

Please provide details

Do you have any known cardiovascular problems (abnormal ECG, heart problems, chest pain etc )?(Required)

Yes

Please provide details

Has your doctor ever told that your cholesterol was too high ? Or that you have a HDL: LDL imbalance ?(Required)

Yes

Please provide details (what were your results?)

Have you (or a family member) ever been told that you have diabetes?(Required)

Yes

Please provide details

Do you have asthma, or any breathing difficulties?(Required)

Yes

Please provide details

Do you have any injuries or orthopedic problems (back, knees, etc)?(Required)

Yes

Please provide details

Do you have stiff or swollen joints?(Required)

Yes

Please provide details

Do you have tension or soreness in any area?(Required)

Yes

Please provide details

Do you wear orthotics?(Required)

Yes

Are you taking prescribed medications?(Required)

Yes

Please list them out below

Are you taking any supplements?(Required)

Yes

Please list them out below

Do you ever have any problems sleeping?(Required)

Yes

Please provide details

Are you pregnant or post-partum (< 6 weeks)(Required)

Yes

N/A

Do you have any other medical condition, injury or anything else we should be aware of that we have not asked you?(Required)

Yes

Please provide details

Have you ever been advised by a doctor, physician or specialist not to perform any type of exercise / activity?(Required)

Yes

Please provide details

Exercise Questionnaire

Are you taking part in any form of exercise or rehab at the moment?(Required)

Yes

Have you taken part in any form of exercise or rehab in the past 12 months?

Yes

Please provide details of your exercise regime

Please include frequency, types of exercise, intensity, etc

Please select any file that you feel are relevant
For example referral letters from your physio, doctor, specialist

File

Drop files here or

Max. file size: 80 MB.

Integra operates a 24h cancellation policy. I understand sessions cancelled within 24h will be charged for.(Required)

Yes

This field is for validation purposes and should be left unchanged.

Fitness + Wellness

Exercise Rehab

Performance

An intelligent approach to fitness + wellness, injury rehab, and performance.

Provided through one-to-one Personal Training or via Distance Coaching

Available at our private studio in London, or virtually.

Find us

Truman Brewery
91 Brick Lane, London, E1 6QL
United Kingdom

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