Online Health Assessment

1
Email* This field is required.
example@example.com
2
Name* This field is required.
First Name
Last Name
3
Have you experienced any recent illness or hospitalization?* This field is required. If yes, please provide details on the next slide.
YESNO
4
Please describe you recent illness or hospitalization
5
Please upload any relevant medical imaging (e.g., X-rays, MRIs, or medical reports) that can share to help us better understand your condition.(optional)
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Select files to upload
Max. file size: 10.6MB
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6
Are you currently under any medical limitations or restrictions for exercise or physical activity?* This field is required.This information helps us create safe programming.
YESNO
7
Please explain your medical limitations or restrictions. This information helps us create safe programming.
8
Please upload any physical therapy homework, exercises, or related documents you currently utilize or practice: We ask this so we can ensure that our work supports and complements your ongoing treatment.
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Select files to upload
Max. file size: 10.6MB
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9
Please list all prescribed medications you are currently taking. Or, upload a document of your list on the next slide:Include the name, dosage (if known), and purpose (optional).
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Ok
Ok
10
(optional) Upload your document(s) of prescribed medications
Drag and drop files here
Select files to upload
Max. file size: 10.6MB
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11
Is there any additional medical information you feel would be helpful for us to know?This may include recent symptoms, past diagnoses, concerns, or anything else you’d like to share.
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Ok
Ok
12
Name* This field is required.
First Name
Last Name
13
Signature* This field is required.Use your finger, mouse, or stylus to sign below.
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