You can always press Enter⏎ to continue
Discovery Visit Request
1
Please Enter Your First Name
*
This field is required.
Previous
Next
Submit
Press
Enter
2
Primary Reason For Wanting To Speak With A Specialist
*
This field is required.
I'm new to physical therapy and am not sure what to expect
I was let down by another physical therapist in the past and would like to see how good you are before I commit
I'm not sure if physical therapy can even help me
I'd like to get a feel for what you can do to help me BEFORE I commit to a full appointment
It's just easier for me doing it this way
Previous
Next
Submit
Press
Enter
3
Where Does It Hurt?
*
This field is required.
Please select one
Back
Knee
Shoulder/Neck
Sports or Exercise Injury
Foot/Ankle
Wrist/Hand
Elbow
Want to stop leaking
Not Sure Where It's Coming From
Please select one
Please select one
Back
Knee
Shoulder/Neck
Sports or Exercise Injury
Foot/Ankle
Wrist/Hand
Elbow
Want to stop leaking
Not Sure Where It's Coming From
Previous
Next
Submit
Press
Enter
4
What Does It STOP You From Doing?
*
This field is required.
Previous
Next
Submit
Press
Enter
5
What's Your Main Concern That Has You Considering Physical Therapy?
*
This field is required.
Please select one
The pain you are experiencing
Fear of not being able to keep active/involved in sporting activity
Worry about not knowing what's wrong
Want to avoid painkillers
Concern at no signs of improvement
Future ill health (and wanting to prevent it)
Please select one
Please select one
The pain you are experiencing
Fear of not being able to keep active/involved in sporting activity
Worry about not knowing what's wrong
Want to avoid painkillers
Concern at no signs of improvement
Future ill health (and wanting to prevent it)
Previous
Next
Submit
Press
Enter
6
How Long Have You Suffered Or Worried?
*
This field is required.
A Few Days
1-2 Weeks
2-4 Weeks
1-3 Months
Long Enough
Too Long (Years)
Previous
Next
Submit
Press
Enter
7
What would be the one thing you would like us to achieve for you?
*
This field is required.
Ease pain
Ease stiffness
Stay active or involved in sporting activity
Avoid painkiller dependency
Find out what's wrong
stop using daily pads
Stay healthy and get better before the pain gets worse
Ease pain
Ease stiffness
Stay active or involved in sporting activity
Avoid painkiller dependency
Find out what's wrong
stop using daily pads
Stay healthy and get better before the pain gets worse
Previous
Next
Submit
Press
Enter
8
Best Phone Number
*
This field is required.
Previous
Next
Submit
Press
Enter
9
Best E-mail
*
This field is required.
Previous
Next
Submit
Press
Enter
10
Tags
Todo
In Progress
Done
Previous
Next
Submit
Press
Enter
Should be Empty:
Question Label
1
of
10
See All
Go Back
Submit