Schoolcraft College Stretch & Recovery Interest Form
Name
*
First Name
Last Name
Age
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Occupation
Do you sit or stand for most of your day?
Sit
Stand
Using the Body Chart, please indicate (circle) any areas of pain or injury
Injury History and Symptoms
Have you had any previous injuries or surgeries?
Yes
No
Please explain:
How did your injury occur?
Sudden Onset
Gradual Onset
Do you feel pain or discomfort with your current injury?
Yes
No
Do you feel pain or discomfort during daily activity?
Yes
No
On a scale of 1-10 how would you rate the severity of your pain:
On Average:
Little To No Pain
1
2
3
4
5
6
7
8
9
Severe Pain and Discomfort
10
1 is Little To No Pain, 10 is Severe Pain and Discomfort
At Worst:
Little To No Pain
1
2
3
4
5
6
7
8
9
Severe Pain and Discomfort
10
1 is Little To No Pain, 10 is Severe Pain and Discomfort
Are you taking any pain relieving medication?
Yes
No
Have you had any previous treatment for this injury?
Yes
No
Please explain:
Is there anything else we should know to help guide your treatment?
Back
Next
I acknowledge that I have read and fully understand this Agreement, that I am giving up substantial legal rights, and that I sign this Agreement freely and voluntarily.
*
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: