Full Name
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Email
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Phone
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Which Service do you need?
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Physical Therapy for Pelvic Health
Physical Therapy for Orthopedics
A Combination of Both
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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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What do you value most when selecting a Physical Therapist?
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Natural treatments
Hands on Care (massage, manual therapy, etc.)
One-on-One Care
Home exercises for quick recovery
What is the main goal you would like us to help you achieve?
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Ease Pain
Ease Stiffness
Stay active or involved in sporting activities
Avoid painkiller dependency
Determine source of issue
Stay healthy/Get better before pain worsens
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