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Name

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Primary reason for wanting to speak with a specialist Primary reason for wanting to speak with a specialist I’m in a lot of pain and want some tips and advice I can start using right away.I would like to know what is wrong and how long it will take to ease.I’m not sure if physical therapy is right for me and talking to a Physical Therapist first would help me decide.Other

Where is your pain or Stiffness? Where is your pain or Stiffness?Lower backNeckShoulderKneeHip/ThighFoot/AnkleHeadacheMuscle StrainPost-Partum PainElbowWrist/HandOther

What is concerning you most? What is concerning you most?The pain you are experiencingNot knowing what’s wrongConcern it has not changedWant to avoid pain medicationFear of not being activeFear of future health issuesOther

How long have you been dealing with this problem? How long have you been dealing with this problem?A few days1-2 weeks1-3 monthsLong enoughSeems like too long (years)

Main goal for speaking with our specialist physical therapist Main goal for speaking with our specialist physical therapistEase painEase stiffnessGet activeAvoid dependency on pain medicationFind out what is wrongStay healthy and get fixed before the pain gets worse

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