ARPwave Strength Training Evaluation Form

Strength Training Evaluation Form

* Indicates required field

Who Referred You? *

Name *

First

Last

Email *

Phone Number *

Phone Number (secondary) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Date of Birth *

Your Physician's Name *

First

Last

Gender *

Phone Number *

School/Employment Status *

Please answer the following:

Are you Pregnant? Y/N *

Are you on Medication or have a history of Blood Clots? Y/N *

Are you using a Pacemaker or ICD? Y/N *

Are you being treated for Cancer? Y/N *

When did your symptoms begin? *

Rate your Pain/Weakness on a 1-10 scale *

Describe your weakness/injury/symptoms *

Which activities bother you the most? *

Please list ALL diagnostic tests performed by any Doctors including X-Ray, MRI, Lab Work, Functional Testing, Psychological Testing, Electrodiagnostics or others. *

Please list ALL treatments you have had including Rest/Ice/Compression, Physical Therapy, Medication, Surgery, Chiropractic, Massage, Alternative or others *

Test Results (if any) *

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 *

Required Field

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Strength Training Evaluation Form

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