Consultation Questionnaire
Physical Therapy, Fitness and nutrition coaching: Specializing in Chronic Pain
Part 1. Contact information
Thank you for your interest with Hope, Health, Healing. Your interest is very important to Dr. Kimberly, PT, DPT. Please allow up to 24 hours to be contacted.
Full Name
*
First Name
Last Name
Gender
*
Male
Female
Date of Birth
*
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Day
Please select a year
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Year
Age
years
Day Phone
-
Area Code
Phone Number
Cell Phone
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Area Code
Phone Number
E-mail
What is the best way to make contact with you?
Best Time to Contact You?
What is your Main Goal or Goals e.g. Strengthening, Weight loss, Chronic pain education/reduction, Nutrition, More Energy?
Please select if you would like learn more about the following
Juice Plus+ Whole Food Nutrition
Tower Garden Areoponic Growing System
Have you trained with a personal trainer before?
Yes
No
Have you had Physical Therapy before
Yes
No
If yes to having Physical Therapy, please provide a short discription of your experience.
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