Consultation History Form
Purpose of this form is to get as clear and accurate picture of your current condition. In general, based on age/sex, how you specifically got hurt, and the activities that provoke your pain/symptoms, I get an idea of the actual issue. Then I'll have you do specific test items to confirm or deny what I think the issue is. Completion of this form gives permission to use answers with personal details removed in marketing material and assumes you want to work directly with us to improve your condition.
Sign in to Google to save your progress. Learn more
Email *
Name you'd like us to call you so we don't open the email with "Hey you!"  *
Did one of us specifically refer you to this request form from a direct message? (this question is NOT required)
Clear selection
What's your age and sex? (this info gives me a sense of potential medical diagnoses that could be related and how I'll keep track of this form)
 *
Enter today's Date: *
MM
/
DD
/
YYYY
Where is your pain located?
*
When did these issues begin?
*
How did this injury happen? *
Describe your pain (check all that apply)
 *
Required
Have you ever seen a Physical Therapist for this before? Did it help?
*
What treatments have you had for it? (meds, injection, rehab from PT or DC, anything you can think of)
 *
What movements or activities have you been forced to stop because of your pain?  *
What movements or activities have you found that DECREASE your pain? *
Have you had any imaging done (xray, MRI, etc). What were the results?
 *
Are there any activities that you'd like to resume doing comfortably now, that you can't do now?
 *
Give me the details of your current exercise program/routine. Are you training for anything specific? *
What can I do for you today that will help you out the most?
 *
So there are no surprises, check "I acknowledge" since the assumption is you've made it this far and you want to work with us. 

As much as we LOVE to chat to people about injuries, we do have bills to pay.

We will review the info you provided and determine if our products and services are the right solution for you.

If we don't think we are the right fit, we can help refer you to someone else in our network. 
 *
Required
Check your inbox
Make sure to check your inbox/spam for "imhurtnowwhat@gmail.com". We typically reply within 24-48 hours.
Submit
Clear form
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms