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Parmele Post Rehab Exercise and Massage
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Questionnaire
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Name
*
First
Last
Email
*
Please list any injuries and surgeries you have had
*
Please list any medical conditions ie: diabetes, high blood pressure
*
Do you experience muscle or joint pain?
*
Yes, on a daily basis
Yes, but less than 2 times a month
Every now and then- few times a year
No, no pain
Describe the type of pain you feel...If none put N/A
*
What exercises/activities help alleviate the pain?
*
What exercises/activities make the pain worse?
*
How much experience do you have with exercise?
*
Exercise at most 1 time a week
Exercise regularly 2 or more times a week
I have exercised on and off for several years
I have never exercised
Please list the type of exercises you do regularly. ie: running, weight lifting, cycling
Do you believe you drink enough water daily?
Yes
No
Unsure
About how many hours of sleep do you get at night?
Is it difficult for you to get on and off the floor?
Yes
No
Do you take prescription pain medication to help ease pain?
*
Yes
No
If yes, how often do you take medication?
What are your goals for this program? What do you hope to achieve?
*
Submit
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