Name *

First Name

Last Name

Issues/Symptoms

What hurts? (check all that apply)

Back

Knee

Neck/Shoulder

Foot/Ankle

Hip

Pelvic Region

Headaches/Migraines

Jaw

Muscle Injury (from sport or exercise)

Not sure

Other

How long have you had this issue?

How long have you suffered or been concerned about this issue?

Haven't, this is preventative

A few days

1-2 weeks

3-4 weeks

1-3 months

Long enough (4 + months)

Too long (1 or more years)

Main concern

What are your biggest concerns that bring you to Physical Therapy? (check all that apply)

The pain I'm experiencing

Not knowing what's going on

Want to avoid pain killers and medication

Fear of not being able to stay active

Risk of needing dangerous surgery

Concern over lack of improvement

Other

Why physical therapy?

Select your reason(s) for choosing to see a Physical Therapist

Natural treatments (no medications or pain killers)

Hands-on care (myofascial release, manual therapy)

One-on-one care

Home exercises and self-treatment to speed up recovery

Ability to limit the possibility of pain returning

Other

Services

What services are you interested in? (check all that apply)

Physical Therapy

Performance Assessment (Wellness & Prevention)

Myofascial Release

Dry Needling

Pelvic Floor Dysfunction

Not Sure