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Functional Assessment Form

A Functional Assessment is a way for you to speak your mind about any and all of your concerns. You may ask any questions you have about your troubles/pain or exercise movements. This is a non-obligation appointment that will give you all of the information you need to make the BEST decision about YOUR health!

Full Name

Email*

Phone

What kind of service are you looking for?

More information about Powerful Physical Therapy

More information about my condition

Functional assessment of my problem

Other

What hurts? or Why did you choose to fill out this form?

What is the MAIN reason you are interested in a Functional Assessment?

I have never seen a Physical Therapist before and am not sure what to expect

I was let down by another Physical Therapist in the past and want to make sure you are a good fit

I am not sure if even Physical Therapy can help me

I would like to get a feel for what you can do for me before deciding to work with you

I want to avoid pain pills and other procedures, including surgery, to fix my problem

How long has this been going on for?

It just happened- only a few days

A few weeks

A few months

Over a year

Not really a problem- I am just looking for prevention or wellness reasons

How is this problem impacting your life?

I can't do certain things I love to do

I am avoiding activity and not pushing myself because I am unsure if it is safe to

I am doing everything - it just hurts or it is annoying

It is not impacting my life yet but I am concerned it might in the future

I am not sure - I just want to speak to an expert about it

Why do you want to take care of this issue now?

What value would Powerful PT bring to your life by helping you?

Not much - I am doing fine - Just want information

Some value - my problem/situation is not that bad

Amazing value - I am in pain and would like for this to be gone

Exceptional value - I am avoiding doing the things I love and it really sucks

Priceless - if what I have is gone despite everything I have tried - it would be AMAZING!

Is there anything else you would like to add about your situation?

How did you hear about Powerful Physical Therapy?

Friend or family member

Instagram

Facebook/YouTube/Social media

Google

Thumbtack

Physician or health care provider

Other

Besides taking care of your issue, what other services would you be interested in learning about?

Sports/Recovery Massages

Wellness Programs

Online Back Relief Program

Personal Training

Preferred Date and Time Available