Current step:1Step 1

2Step 2 - Complaint/Pain

3Ste 3 - Medical History

4Step 4 - Occupation and Condition

5Step 5 - Fitness Level

6Step 6 - Recovery Therapy

MAI Therapy Assessment Form

January 23, 2026

Step 1 - CONTACT INFORMATION

Male

Female

Do we have permission to contact your physician regarding your treatment at Muscle Activation Israel Therapy? *

YES

Does your physician know you intend on participating in treatment and/or an exercise program? *

YES

** Please, bring any reports/documents of imaging that you have had done in the past (ie. X-Rays MRI’s, etc.), if applicable.

Step 2 - CURRENT COMPLAINT/PAIN

What is your current complaint/pain? *

What movements or activities are limited? *

What, if anything makes your condition worse? *

What, if anything makes your condition better? *

Have you had any of these conditions in the past? *

YES

Was it resolved? *

YES

Please choose any areas which you are presently experiencing discomfort and/or pain (use figure below for the reference)

Right shoulder

Right hip

Lower back

Right knee

Left shoulder

Left knee

Left hip

Step 3 - MEDICAL HISTORY

Are you currently taking any medications or drugs? *

YES

Please list them by name and/or associated purpose *

Do you have any of the following currently or have had in the past

Any history of heart problems? *

YES

High/Low blood pressure? *

YES

Any chronic illness or conditions? *

YES

Please explain problem or condition *

When were you diagnosed (approximate) *

By whom it was diagnosed *

Are you currently receiving treatment for it? *

YES

Please describe the treatment *

Do you have any surgery history? (dental, cosmetic included) *

YES

Please list the surgeries *

Do you have any of the following:

History of lung or breathing problems? *

YES

Diabetes? *

YES

Smoking habits? *

YES

Hernia or any condition that may be aggravated? *

YES

Orthopedic (bone/joint) issue? *

YES

Please explain bone/joint issue *

Muscular issue? *

YES

Please explain muscular issue *

Back disorder? *

YES

Please explain back disorder *

Step 4 - CURRENT OCCUPATION AND CONDITION

What is your occupation? *

What are your main occupational activities?

On the phone

Computer work

Sitting

Walking

Driving a vehicle

Repetitive movements

Standing

Lifting/bending

Other

Please describe Other activities *

Do you have any difficulty with activities of daily living?

YES

Please explain the difficulties *

Are you currently pregnant? *

YES

Have you been pregnant within the last 5 months? *

YES

If you have been pregnant in the past more then 5 month ago, how many times? *

Please list conditions relating to having been pregnant if any? *

Step 5 - FITNESS & WELLBEING

Do you do any formal exercise? (e.g., lifting weights, running, etc) *

NEVER

SOMETIMES

OFTEN

What kind of formal exercise do you do? *

How many times per week do you exercise?

Do you do any informal exercise? (e.g., walking, chores, etc) *

NEVER

SOMETIMES

OFTEN

What kind informal exercise do yo do? *

Have you been sedentary (inactive) for the past year or more? *

YES

Approximately how many hours do you sleep per night? *

Do you wake up during the night? *

NEVER

SOMETIMES

OFTEN

What time do you wake during the night? *

Please describe your sleep (quality) *

Do you have fatigue during the day? *

YES

How would describe the emotional climate of your home? (1 = very bad; 10 = very good) *

Please rate the level of stress at your work or in other aspects of your life. (1 = very low; 10 = very high) *

Please describe the nature of your stress *

Rate your diet. (1=very unhealthy; 10 = very healthy) *

Describe what needs the most improvement in your diet *

Approximately how much water (in litres) do you drink per day? *

Step 6 - RECOVERY THERAPY

How much time are you willing to devote to your recovery process?

Minutes per day *

Days per week *

Are you currently using other health care methods? *

None

Physiotherapy

Chiropractic

Acupuncture

Reflexology

Osteopathy

Psychotherapy

Massage

Other

Please describe Other method *

How did you hear about Muscle Activation Israel Therapy? *

Is there anything that you feel is important that has not been covered?

Patient consent *

I/We hereby understand and acknowledge that the services, training, programs and events held by Muscle Activation Israel Therapy may expose me to many inherent risks, including accidents, injury, and/or illness. I/We assume all risk of injuries associated with participation including, but not limited to, falls, contact with other participants, and all other such risks being known and appreciated by me.

I/We hereby acknowledge my responsibility in communicating any physical and psychological concerns that might conflict with participation in activity. I/We acknowledge that I am physically fit and mentally capable of performing the physical activity I chose to participate in.

After having read this waiver and knowing these facts, and in consideration of acceptance of my participation and Muscle Activation Israel Therapy furnishing services to me, I agree, for myself and anyone entitles to act on my behalf, to HOLD HARMLESS, WAIVE AND RELEASE Muscle Activation Israel Therapy, its officers, agents employees, organizers, representatives, and successors from any responsibility, liabilities, demands, or claims of any kind arising out of my participation in Muscle Activation Israel Therapy services, training, programs, and/or events.

By check in the box and submitting this form I/We indicate that I/We have read and understand this Waiver of Liability. I am aware that this is a waiver and a release of liability and I voluntarily agree to its terms.

Parent’s consent if patient is under 18 years of age *

I represent that I have legal capacity and authorize to act on behalf of the minor named herein.

MAI Therapy Assessment Form

Step 1 - CONTACT INFORMATION

Step 2 - CURRENT COMPLAINT/PAIN

Step 3 - MEDICAL HISTORY

Step 4 - CURRENT OCCUPATION AND CONDITION

Step 5 - FITNESS & WELLBEING

Step 6 - RECOVERY THERAPY

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