MAT Health Questionnaire (MATH-Q)

Instructions: To help us serve you better, complete the form below as thoroughly as possible prior to your first MAT session.

Full Name
Email
Phone
  1. Have you ever experienced Muscle Activation Techniques, or any therapy/treatment of your muscular system? (Physical Therapy, Massage, Rolfing, A.R.T., etc.) No  Yes
    If so, what was your experience with it?
  2. Can you recall any specific injuries in your life where a bone was broken or dislocated/subluxed, a ligament, tendon or muscle was strained or torn, or a joint sprained or abnormally swollen? If yes, please describe.
  3. How active are you each week? (Think in terms of intentional exercise, times performed, duration of time and the level of intensity)
    High  High to Moderate  Moderate  Moderate to Light  Light
  4. If applicable, how energized do you feel after your workouts or intentional activities? Please note your level of soreness, the symmetry of that soreness (i.e. does it feel the same on both sides of your body), how long it lasts, and how energized immediately after the workout.
  5. Do you wear orthotics, or shoe inserts in any of your foot attire and do you consistently use them? Please list the intention behind their use and how you were outfitted for them (were you assessed from a static position or were you moving?).
  6. Do you wear shoes with a moderately high to very high heel? If so, how long do you wear them and what do you do in them? Also, please describe how you feel after wearing them.
  7. How much water do you drink in a day (cups/liters) and what percentage of your intake is not water? Describe.
  8. Do you feel you maintain a healthy diet? No  Yes
    Please provide some detail of a typical day of eating.
  9. Do you consume alcohol? No  Yes
    If yes, how many drinks per day/week:
  10. Do you smoke cigarettes or have you in the last five years? No  Yes
    List frequency and quantity:
  11. Do you sleep 6-8 hours a day (including naps)? No  Yes
  12. How would you view your sleep quality?
    Broken and erratic where you wake up tired  Solid and deep waking up refreshed  Something in-between
  13. Are you currently taking any over-the-counter or prescription medications, or have you recently (in the last 5 years) stopped taking medications? If yes, please list their full name, their potential side effects, how long you have taken them and what the intention of taking the medication is.
  14. Without providing intimate details, how emotionally stressed do you feel your life is?
    High  High to Moderate  Moderate  Moderate to Light  Light
    Expound if you would like:
  15. Do you currently have a doctor, chiropractor, osteopath, physical therapist, or some other type of therapist? If so, could you provide his or her information so I can maintain open communication on what it is we are working on together?
  16. What is the best way you learn information?
    Auditory - listening  Kinesthetic - hands on  Visual - you need to see models or material related to the topic 
  17. What is the most important thing you want as an outcome by seeing a Muscle Activation Techniques Specialist?