Full Name
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Email
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Phone
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What is your primary reason for contacting us?
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I'm new to physical therapy and am not sure what to expect
I was let down by another physical therapist in the past and would like learn more before I commit
I'm not sure if physical therapy can even help me
I'd like to get a feel for what you can do to help me BEFORE I commit to a full appointment
It's just easier for me doing it this way
Where does it hurt/What is your area of concern?
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Hip Pain/Tightness
Neck Pain
Knee Pain
Foot Pain/Tenderness
Lower Back Pain
Pelvic Pain
Urinary Incontinence
Constipation
Pain with Intercourse
Pregnancy/Prenatal Wellness Care
"Mom Pooch" Diastasis Rectis Abdominis
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What does it STOP you from doing?
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What concerns you most about this issue?
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The pain I'm experiencing
Fear of not being able to keep active/involved in sporting activity
Concerned about not knowing what's wrong
I'd like to avoid painkillers
Concerned about lack of any improvement
Future ill health (and wanting to prevent reoccurrence)
I'm doing well now, and want to stay in good health
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How long have you suffered/worried about this?
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A few days
1-2 weeks
Less than a month
1-3 months
Years
Looking for preventative/wellness care
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