ONLINE PHYSICAL THERAPY APPLICATION

Name*

First NameLast Name
ONLINE PHYSICAL THERAPY APPLICATION

Please apply if you are currently experiencing any pain, discomfort and/or longstanding injuries that need help recovering from and are interested in a virtual injury evaluations. Within this first zoom evaluation we will go over your injuries, perform virtual assessments and create a treatment plan. The investment for this first evaluation is $175, however, if after the evaluation you feel this investment is right for you, the payment for the evaluation will be comped and go towards your treatment plan cost. Within these individualized rehab programs, there will be weekly check-ins, virtual calls, individualized exercise plans to facilitate recovery, access to ask questions and submit form critique. Revitalize Recovery will reach out to schedule your evaluation following your application.
Email*
Phone Number*
Date of Birth*

MonthDayYear
Date
Please explain your current injuries/pain that you are looking to get evaluated for:*
When did your symptoms begin (2 weeks, yesterday, on/off 10 years, etc.)?*
On a scale of 0/10, what is your current PAIN level? *
(0 being none at all, 10 being the worst you’ve ever experienced)
What is your current exercise compliance?*

Don't currently exerciseExercise < 3 days/weekExercise 4-5 days/weekExercise 6-7 days/week
Describe any activities or movements that AGGRAVATE your symptoms?*
Describe any activities, movements or self-care that DECREASES your symptoms?*
What other types of treatment have you had for the symptoms (physical therapy, chiropractic care, massage, medication, imaging, etc.)?*
Have you ever worked with a physical therapist online?*

YesNo
What else would you like us to know about your symptoms and/or injuries?
Instagram Handle (if applicable)?
Do you prefer to be reached by text message, email or instagram?*
What is your general availability (best day/time for an evaluation)?*
What time zone are you located in? *
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