First Name
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Last Name
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Phone Number
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Email
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Where are you experiencing pain or limitation?
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Upper Body (Neck, Shoulder, Elbow, Wrist, Hand/Fingers)
Lower Body (Hip, Knee, Leg, Ankle/Foot)
Spine & Core (Back, Midsection)
General / Whole Body (Generalized Pain or Stiffness, Balance/Coordination, Mobility/Flexibility Limitations)
Other (Post-Surgical Recovery, Injury Prevention/Wellness Care, Other)
On a scale of 1–10, how severe is it?
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(1 = very mild, 10 = most severe)
When did you first start noticing this pain or limitation?
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(Approximate dates are fine - even “a few weeks ago” or “last year” helps us understand your situation.)
How is this affecting work, hobbies, or daily living?
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(Difficulties walking, lifting, sleeping, sports, work, daily chores, etc.)
What do you hope to achieve with therapy?
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(Reduce pain, return to sport, improve mobility, post-surgery recovery, general strength)
Additional information that may help us provide the best care:
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