Submit
Fitbliss Physical Therapist Consultation Form
Name
First Name
Last Name
Email
example@example.com
Birthdate
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What Fitbliss program are you currenly doing?
Fitbliss All-In
Fitbliss Nutrition Only
Fitbliss Personalized Workouts only
Fitbliss Lifting Club
Fitbliss Lifting Club + Nutrition
Fitbliss Ladies Lift Classes
None/Other
Who is your Fitbliss Coach?
Please list your current height and weight:
Please list any previous injuries or surgeries you've had:
What is your reason for consulting with a Physical Therapist (check all that apply)
Recent injury/trauma
Nagging chronic pain from past injury
Nagging chronic pain - unknown origin
Pain when performing certain exercises
Pain when performing basic daily activities
Other
Please provide detailed context for any boxes you've check above: (be as detailed as possible)
On a scale from 1 - 10 (ten being the worst) how would you rate your pain while performing daily activities
1
2
3
4
5
6
7
8
9
10
Have you seen a medical professional of any kind about this issue? If yes, when was this and what was their prognosis?
How long have you been dealing with this issue?
What movements or activities are the most bothersome?
Please tell us a bit about your daily physical activity:
Please tell us about your weekly exercise routine:
Please tell us about the time that you felt the most physically fit and able:
Please list any additional questions or concerns you'd like to discuss with your PT:
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