One-Time Intake

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Section 1

About You

1. How long have you been working night shift?

Less than 1 year 1–5 years 6–10 years 10+ years

Section 2

Injuries & Physical Limitations

2. Which areas give you the most trouble?

Select all that apply

Hips Lower back Knees Feet / ankles Shoulders / neck Head (migraines) No major pain areas

3. Has a doctor or PT ever given you any restrictions?

Yes — no high impact (running, jumping) Yes — limited bending / squatting Yes — other restrictions No formal restrictions

4. Which of these can you do without significant pain?

Select all that apply

Walk 20+ minutes Go up and down stairs Squat or sit low Stand for long periods Light stretching None of these comfortably

5. On a bad pain day, how bad does it get?

Mild — barely noticeable Moderate — there but manageable Bad — affects what I can do Severe — really hard to function

6. How often do you get migraines?

Rarely (few times a year) Monthly Weekly Almost daily I don't get migraines

7. Do you know what triggers your migraines?

Select all that apply

Poor sleep Stress Dehydration Bright lights or screens Skipping meals Not sure N/A — no migraines

Section 3

Hip — Deep Dive

8. How long have you been dealing with hip issues?

Less than 6 months 6 months – 1 year 1–3 years More than 3 years N/A — no hip issues

9. Describe where exactly the hip pain is.

e.g. front of hip, side, deep inside, groin area, down into the thigh

10. What does the hip pain feel like most of the time?

Select all that apply

Sharp / stabbing Dull ache Tight / stiff Burning Clicking or popping Grinding sensation

11. When is the hip pain worst?

Select all that apply

First thing in the morning After sitting for a long time During or after standing / walking During exercise or training At night / when trying to sleep After a long shift

12. Does anything make the hip feel better?

Select all that apply

Heat Rest Stretching Movement / walking it out Nothing really helps Haven't figured that out yet

13. Does the hip pain ever travel anywhere else?

Select all that apply

Down the front of my thigh Down the outer thigh Into my lower back Into my groin No, it stays in one spot

14. How much does the hip limit you during training?

I barely notice it while training I notice it but push through I modify certain movements because of it It stops me from training some days

Section 4

Neck — Deep Dive

15. Where exactly is the neck pain or tension?

e.g. base of skull, right side, both sides, runs into shoulders

16. What does it feel like?

Select all that apply

Stiff / hard to turn Dull constant ache Sharp when I move a certain way Causes tension headaches Tingling or numbness into arms / hands Mostly just tightness after long shifts

17. What makes the neck worse?

Select all that apply

Looking down at a phone or screen Stress Long shifts — standing or moving all night Sleeping position Certain exercises I'm not sure

18. Does neck pain cause headaches?

Yes — almost every time it flares Sometimes Rarely No, they seem separate I don't have neck issues

Section 5

Shoulder — Deep Dive

19. Which shoulder?

Left Right Both I don't have shoulder issues

20. Describe where you feel it in the shoulder.

e.g. front, top, deep inside, radiates down the arm

21. What does the shoulder feel like?

Select all that apply

Dull ache Sharp when reaching or lifting Weak — hard to hold things overhead Clicking or popping Stiff — limited range of motion Mostly fine at rest, only during movement

22. What movements bother it most?

Select all that apply

Reaching overhead Reaching across my body Lifting things out in front Behind the back / clasping Sleeping on that side Pressing movements (push-ups, overhead press) Nothing specific — it just aches

23. How long have you had shoulder issues?

Just recently (under 3 months) A few months 1–2 years More than 2 years N/A — no shoulder issues

Section 6

Sleep

24. After a night shift, how many hours do you usually sleep?

Less than 4 hours 4–5 hours 6–7 hours 7+ hours

25. How would you describe your sleep quality most of the time?

Very poor — rarely feel rested Poor — occasionally decent Fair — some nights are okay Good — mostly feel rested

26. What most often disrupts your sleep?

Select all that apply

Pain or physical discomfort Can't turn my brain off Noise or light Needing the bathroom Just wake up randomly Sleep is usually fine

Section 7

Stress

27. What is your biggest source of stress right now?

Select all that apply

Work demands Not enough rest or recovery time Health and pain Family responsibilities Financial pressure All of the above

28. When you're off work, what does a typical day look like?

Mostly resting and recovering Mix of rest and light tasks Busy — errands, family, obligations Rarely have downtime

29. Is there anything outside of work that consistently stresses you out?

Optional — a few words is fine

Section 8

Overall

30. What is your main goal right now?

Reduce pain and feel better physically Have more energy day to day Sleep better Feel less stressed and overwhelmed All of the above

31. How are you feeling overall going into this?

😞 Not great — really struggling 😐 Just getting by 🙂 Okay — making some progress 😊 Good — feeling some momentum

32. Anything else you want me to know?

Optional — physical, mental, anything at all

Your Answers

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