Rebuild New Client Intake Form
First Name
*
Last Name
*
Email
*
Phone
*
Date of birth
*
City
State
Postal Code
Country
Enter your country
Medical History (Please include current diagnoses, past surgeries, current medications, etc.)
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Has any doctor currently restricted or advised against any movement or activity for you?
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Yes
No
Select all the places your pain shows up.
*
Head
Neck
Shoulder
Hand (Elbow, Wrist)
Upper Back or Mid Back
Low Back
Hip
Knee
Ankle / Foot
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Describe what your pain feels like.
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Sharp
Shooting
Numbness and Tingling
Achy
Tender To Touch
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How long have you experienced this pain?
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Select an option
What have you tried so far to help with the pain?
Physical Therapy (Physiotherapy)
Exercise Program (Strength, Yoga, Pilates, etc.)
Dry Needling or Accupuncture
Massage Therapy
Chiropractor
Injections (Cortisone, PRP, Prolotherapy, etc.)
Pain Management Specialist
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What makes it worse?
What makes it better?
Are there any movement restrictions?
Are there any dietary restrictions?
List your top 3 goals for this program
*
What equipment do you have access to? (Resistane bands, yoga mat, yoga block, dumbbells, pilates ball, etc.)
How much time can you commit each day?
Less than 20 min
20 to 30 min
30 to 45 min
What day of the week works best for you? Please include a preferred time.
Is there anything else you would like your coach to know before the kick-off call?