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Movement Improvement: Pre-Screen
This form will give me information on your current injury or issue and allow me to develop a plan of action to assist you in recovery
Name
Your answer
Phone Number
Your answer
Email
Your answer
Best Days/Times to Schedule Session
What is currently bothering you?
Your answer
Where does it hurt? Specific body part and also which area (ex: inner left leg, closer to knee)
Your answer
Does the pain/tension refer elsewhere? (Ex: many times back pain can refer down into the hip)
If you answered yes above, where does the pain refer to?
Your answer
What movements bother it or make the pain worse? What portion of the movement or action causes pain?
Your answer
What movement does it restrict?
Your answer
What movements make it feel better?
Your answer
Does it feel like joint or muscular pain?
Is your flexibility restricted?
Have you had this examined by a doctor?
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