True Self Health - Pain & Physiotherapy Questionnaire

True Self Health - Pain & Physiotherapy Questionnaire
The information you provide will help us understand how to best support you in reaching your health and performance goals.

Please set aside 5 - 10 minutes of intentional space to respond to these questions. This is an opportunity for self-reflection and to see if working together feels like a good fit for us both. All answers are confidential.
PERSONAL DETAILS
Name

First NameLast Name
Email
example@example.com
Where are you located?
CLIENT INFORMATION
What is the primary issue(s) that I can help you with?
When did the injury happen? How did it happen?
What physical limitations do you face in your daily life due to the pain/injury?
On a scale of 1 to 10, what is your level of pain (on average)?

1

2

3

4

5

6

7

8

9

10

1 is Minimally Stressed, 10 is Severely Stressed
Describe your pain - frequency, location, duration, level of pain, etc.
Do you feel that stress contributes to your pain/injury? How so?
What aspect of our work together do you feel can help you the most? (traditional PT, breathwork, manual therapy, strength training, mindset & meditation, etc)
What sports/activities/hobbies do you intend on engaging in once you recover to full health, strength, and performance?
How would you describe your relationship to your 'True Self'? (Mind, Body, Health, Heart, Purpose, and Spirit)
Please include anything else that you would like to share:
Upon completing this form, you will recieve a follow up email with information about how to book a session for those ready to start. Additionally, a link for a discovery call will be included if you'd like to discuss anything with Dr. Justin before moving forward.
Physical Therapy Sessions with Dr. Justin Ternes are self-pay with insurance reimbursement upon request. Inital Evaluations are $280(Current Specialty Pricing $225). Follow-up sessions $220(Current Specialty Pricing $180). *Specialty Pricing ends August 30th. Sessions decrease in price if more sessions you purchase.

If you would like to continue working together after physical therapy is complete, we can explore breathwork and mindset coaching to transition into health and performance optimization.

All Packages include premium access to online courses, our online community, and more! More info to be shared after our discovery call.
Disclaimer: Before beginning any new health practices, please consult your primary care physician. While I am a licensed physical therapist, our work together is conducted in a health coaching capacity. This coaching is intended to support the mind-body connection, deepen your understanding of pain science, teach breathwork and stress regulation techniques, and help improve your relationship with your pain experience. I do not provide medical diagnoses, nor do I treat pain or injuries. By clicking below, you acknowledge and understand that the guidance provided is for general health and wellness coaching and is not a substitute for professional medical advice, diagnosis, or treatment. For any specific health concerns, please consult your healthcare provider.
Thank you for trusting me with the opportunity to work together. I look forward to connecting with you and learning about your story.

— Dr. Justin Ternes
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True Self Health - Pain & Physiotherapy Questionnaire

The information you provide will help us understand how to best support you in reaching your health and performance goals.

PERSONAL DETAILS

CLIENT INFORMATION