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 main issue(s) that I can help you with? *
How long has this been going on?*
What aspect of our work together do you feel can help you the most? (breathwork, traditional PT, manual therapy, cold-exposure, mindset coaching, strength training, mindfulness/meditation, etc)*
What sports/activities/hobbies do you intend on returning to in full health, strength, and performance?*
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:*
On a scale of 1 to 10, how much stress do you experience on a daily basis?*

1

2

3

4

5

6

7

8

9

10

1 is Minimally Stressed, 10 is Severely Stressed
What are the primary factors that contribute to your stress?*
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:*
Pain, Performance, and Physiotherapy Packages:

5-Week Program - 5 Weekly Sessions aimed to support you in resetting your mind-body and nervous system.
3-Month Program - Looking for continuous growth and support? This is a great plan that builds on the foundation of breath.
6-Month Program - This program is for those looking to take their practices to another level. Transform in mind, body, spirit.

All Packages include premium access to online courses, our online community, and more! More info to be shared after our discovery call.
What coaching option are you interested in?*

6-Month Package3-Month Package5-Week PackageInitial EvaluationNot Sure Yet
More information on packages will be sent in the follow up email along with a link for a discovery call if you'd like to discuss anything with Justin before making your payment.
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.*

I understand and agree
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
Should be Empty:

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