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This is the Consult Form for Physical Therapy Services with Osano Training Concepts LLC provided by Dr. Jeremy Butao, PT, DPT. Please answer each question as accurately as possible and we will get back to you as soon as we can. Thank you!
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First & Last Name *
Date of Birth *
Gender *
Height (specify in or cm)
 *
Weight (specify lbs or kg)
 *
Email *
Phone Number *
Address *
Emergency Contact First & Last Name *
Emergency Contact Phone Number *
What are your current symptoms? *
What location of your body are you having pain or abnormal sensation? *
When did your symptoms begin? *
Was onset gradual or sudden? *
Since onset, are symptoms getting: *
Have you had similar symptoms in the past? *
Have you had more than one episode? *
Which of the following best describes how your injury occurred (if your condition is post-surgical, please indicate as per original injury)? *
Required
Nature of pain/symptoms. Check all that apply. *
Required
Throughout the day do your symptoms. Check one. *
Does the pain wake you up at night? *
Since onset of your current symptoms, have you had: *
Required
Have you had any previous treatment for this condition? *
Have you had any imaging done (MRI, X-ray, CT scan)? *
What aggravates your symptoms? Check all that apply. *
Required
What relieves your symptoms? Check all that apply. *
Required
Please list any prescription medications you are currently taking (pain pills, injections and/or skin patches, etc). *
How would you rate your general health? *
Poor
Excellent
Do you exercise outside of normal daily activity? *
Have you ever been diagnosed with any of the following conditions? Check all that apply. *
Required
Do you smoke? If yes, how much? *
Are you currently pregnant? *
Occupation: *
Physical activities at work. Check all that apply. *
Required
Are you currently receiving or seeking disability for this condition? *
If not performing your normal activities at work, do you plan to return to your previous activity level? *
What service are you interested in? Check all that apply. *
Required
If you use social media to log your training, kindly provide the platform and your username below.
How did you hear about us? *
Do you have any additional comments, questions, or concerns? *
CONSENT: I consent to the use of the provided information for health assessment and potential services by Osano Training Concepts LLC, understanding that no immediate services will be initiated based solely on this form.
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