*Primary Reason For Wanting To Speak With A Specialist? What Option Best Describes You?
1. I'm new to physical therapy and am not sure what to expect
2. I was let down by another physical therapist in the past and would like to see how good you are before I commit
3. I'm not sure if physical therapy can even help me
4. I'd like to get a feel for what you can do to help me BEFORE I commit to a full appointment
5. It's just easier for me doing it this way
Where Does It Hurt? Which Option Best Describes You?
1. Back
2. Knee
3. Hip
4. Shoulder/Neck
5. Sports or Exercise Injury
6. Foot/Ankle
7. Not sure where it's coming from?
8. Pelvis
9. Other
*What Does It STOP You From Doing?
*What Is Concerning You The Most? What Option Best Describes You?
1. The pain you are experiencing
2. Fear of not being able to keep active
3. Worry about not knowing what's wrong
4. Want to avoid painkillers
5. Concern at no signs of improvement
6. Future ill health (and wanting to prevent it)
7. Public embarrassment from incontinence
8. Difficulty with intimacy and/or conception
*How Long Have You Suffered Or Worried? What Option Best Describes You?
1. A Few Days
2. 1-2 Weeks
3. 2-4 Weeks
4. 1-3 Months
5. Long Enough
6. Too Long(Years)
*What Would Be The One Thing You Would Like Us To Achieve For You? What Option Best Describes You?
1. Ease Pain
2. Ease Stiffiness
3. Stay active or involved in sporting activity
4. Avoid painkiller dependency
5. Find out what's wrong
6. Get better before the pain gets worse
7. Improve intimacy and/or ability to conceive
8. Improve bladder control
*Best Day and Time to Call
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