Online Picture Therapy Form
Please take a moment to fill out the form below.

Once you submit your form, your four posture photos, and your payment your therapist will send you your personalized e-cise menu with pictures, instructions and videos to your email within 24 business hours.

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Name (First & Last): *
Email: *
Phone: *
Date of Birth:
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Occupation:
Please Choose A Therapist: *
Have you done any Posture Therapy before?
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Have we worked with any of your family members or friends?
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How did you hear about us?
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If other, please explain:
Have you seen a physician or other healthcare practitioner about your current symptoms(s)?
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Where is your primary area of pain?
What would you rate this pain?
What is your secondary area of pain, if any?
What would you rate this secondary pain?
Explain location and rate any additional pains you may have:
What are your limitations?
How much water do you drink per day? (One glass is ~8 oz.)
Do you participate in group workouts?
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Do you workout with a trainer?
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Describe your average sleeping hours and pattern:
Do you smoke?
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Are you taking any medication?
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How many hours a day do you spend sitting?
What else would you like your Posture Therapist to know about you, your goals or your pain symptoms?
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