Get startedBook a free consultation with us to see how we can help. Name * First Name Last Name Email * Phone * (###) ### #### Date of Birth * MM DD YYYY Occupation * Age * How did you hear about us? * What outcomes/results are you seeking? * Medical History Briefly explain any prior injuries/surgeries. * Please list any prescribed or over the counter medications you take and why you take them. Have you ever been diagnosed with any of the following? Arthritis Diabetes High Blood Pressure Asthma High Cholesterol Balance issues or any problems with dizziness Chest pains In the past 12 months have you... Used tobacco products Used E-cigarettes Averaged more than 5 alcoholic beverages per week Had a physical Exam Please provide additional info if you answered "yes" to any of the boxes above. Do you have any of the following symptoms? Pain Tingling Numbness If "yes", please list which areas correspond with each symptom. When do you experience your symptoms? I.E do certain activities increase symptoms? Does anything seem to relieve the symptoms? If yes, please explain. * Do you have a current exercise routine? * Are you following a nutrition plan? * Do you think you get an adequate amount of sleep? How many hours per night? * Do you have difficulty performing daily activities like walking, sitting, taking the stairs? Briefly explain. * If you perform routine physical fitness, what types of workouts or walking routines do you enjoy? Thank you!
