Client Physical Therapy Questionnaire

Client Questionnaire
Please fill out the form below, so that we can serve your specific need, please tell us how you want us to help …
(it will take less than 60 seconds!)
I am a*

maleFemaleI live aloneI live with my partner/husband/familyOther
Today's Date*

MonthDayYear
Your Full Name*
Your Email*
Your Phone*
Your City/State*
Caregiver / partners /spouse name*
Health?*

goodfairpoorOther
Please tell me the issues you are experiencing*

Unsteadiness on my feetDifficulty walkingFear of fallingGeneralized weakness / DeconditioningDifficulty performing activities in the homeDifficulty /needing assist leaving the homeUnable to do the things I enjoyOther
How motivated are you to achieve your goals*

Not motivatedSomewhat motivatedvery motivatedOther
Do you have someone that can help / support you achieving your goals*

nopartner /husbandchildren /grand childrenpaid caregiverOther
Are you aware that we do not accept insurance and that this is a out of pocket expense*

yesno
Please provide me with any other information that you think is relevant and what time is best for me to contact you*
Thank you. We will get back to you within 48 hours

Sincerely

Cornelis (aka Kees) Verdaasdonk
Should be Empty:

Client Questionnaire