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Strength Training Evaluation Form
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Name
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Your Physician's Name
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Phone Number
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School/Employment Status
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Please answer the following:
Are you Pregnant? Y/N
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Are you on Medication or have a history of Blood Clots? Y/N
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Are you using a Pacemaker or ICD? Y/N
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Are you being treated for Cancer? Y/N
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When did your symptoms begin?
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Rate your Pain/Weakness on a 1-10 scale
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Describe your weakness/injury/symptoms
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Which activities bother you the most?
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Please list ALL diagnostic tests performed by any Doctors including X-Ray, MRI, Lab Work, Functional Testing, Psychological Testing, Electrodiagnostics or others.
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Please list ALL treatments you have had including Rest/Ice/Compression, Physical Therapy, Medication, Surgery, Chiropractic, Massage, Alternative or others
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Test Results (if any)
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Truthful Representation:
Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell My Back and Body Clinic as soon as possible so that it can be added to my record:
ALL INFORMATION IS TRUE
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Home
Back Care
Overview
>
Jane's Testimonials
View a session
Private Sessions
Small Group Classes
Workshops
ARPwave
Scoliosis Plan
ARPwave System for Injury Recovery
>
ARPwave Strength Training Evaluation Form
ARPwave Strength Fees
ARPwave Neuro Tune Ups
Rehabilitative Personal Training
Rehabilitative Training, Personal Coaching, Bi-monthly Tune Ups
SandDune Stepper
Dune protocols
Contact Jane
Contact Russell
Our Stories
Jane
Russell
Blog
We can Come to You
FAQ and Clinic Policies
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