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Rehab Coaching Intake
Please complete this form to the best of your ability to provide preliminary information for Dr. Alan Wu prior to your initial evaluation.
24
Questions
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1
Name
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First Name
Last Name
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2
E-mail
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Please Provide a Correct Working Email
example@example.com
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3
Phone Number
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4
Instagram Handle
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5
Emergency Contact
Name
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6
Emergency Contact Phone Number
Please enter a valid phone number.
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7
Occupation
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8
Briefly Describe Your Current Training Goals
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9
Best describe where the pain is occurring.
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10
When did this pain first start?
-
Date
Year
Month
Day
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11
Have you already seen a medical professional for this?
YES
NO
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12
Have you gotten any scans and/or imaging done?
YES
NO
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13
If you have seen a medical professional, what was the diagnosis?
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14
What have you tried to ease your symptoms?
Exercise, physical therapy, medication, other. (describe in as much detail as possible)
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15
Rate your symptoms from a scale of 0-10
(overall, not limited to pain)
0 - I feel Great
1
2
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10 - I need to Call 911 Now
Other
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16
Please rate your concern for the symptoms from 0-10
0 - Im not concerned
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2
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10 - I'm worried sick
Other
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17
What is your pain, at best, in daily life.
0- No Pain
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9
10 - Worst Pain Possible
Other
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18
What is your pain, at worst, in daily life.
0- No Pain
1
2
3
4
5
6
7
8
9
10 - Worst Pain Possible
Other
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19
What aggravates your symptoms in daily life?
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20
What is your pain, at best, in training.
0- No Pain
1
2
3
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9
10 - Worst Pain Possible
Other
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21
What is your pain, at worst, in training.
0- No Pain
1
2
3
4
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7
8
9
10 - Worst Pain Possible
Other
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22
Which lifts aggravate your symptoms?
Squat
Bench
Deadlift
Other
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23
Appointment Type Preference
Remote
In-Person (Boston, MA)
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24
Anything else you'd like me to know?
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