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Injury Questionnaire
Valley Spine & Sport
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Email
*
Your email
Name and Age:
Your answer
Describe your main complaint(s) and symptoms.
Your answer
Describe HOW and WHEN your symptoms began.
Your answer
List any important medical or injury history.
Your answer
What makes the symptoms better?
Your answer
What makes the symptoms worse?
Your answer
Have you seen any other health care professionals for this condition.
Yes
No
If yes, who did you see and what tests (X rays, MRIs, etc) and treatments were provided?
Your answer
Rate your level of function with 100% being normal.
Your answer
What are you looking to do that you are currently unable to do because of these symptoms.
Your answer
Any questions for us?
Your answer
Who would you like to see or is there a specific procedure you are interested in?
Next Available/Any Provider
Kelly Ashbeck, Orthopedic Physical Therapist
Alex Tapplin, Sports Chiropractor
Lace Luedke, DPT, PhD for a running gait assessment
Laser Therapy
Dry Needling
Shockwave Therapy
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How would you like to be contacted?
Email
Phone
Text
Leave phone # if that was your preference above.
Your answer
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