Main Reason for Requesting a Physical Therapy Appointment?*
(Please select one )

Physical Therapy Evaluation and TreatmentCardiovascular Rehabilitation TherapyPulmonary Rehabilitation TherapyBalance/Fall Risk RehabilitationDizziness/Vestibular RehabilitationUrinary Incontinence/Pelvic Floor DysfunctionOrthopedic RehabilitationPhysical Therapy post-surgeryInspiratory Muscle TrainingGroup ClassOther

What Is Your Current Problem For Which You Are Seeking Physical Therapy?*
(Please select all that apply)

I have pain/stiffness/muscle weakness/tingling/ numbnessBackNeckKneeAnkleHipShoulderelbowHand/wristMuscle injuryMultiple body partsOther not listed above
I have breathing difficulty/difficulty clearing my phlegm
I have repeated chest infection or repeated hospitalization due to chronic lung disease
I suffer from chronic lung disease eg. COPD, Cystic fibrosis etc.
I have suffered from a heart attack/heart failure or had a heart surgery and am afraid to exercise
I have poor balance/had a fall and want to prevent falls
I am dizzy and would like to inquire about vestibular rehabilitation
I have problems with urinary incontinence
I am an athlete who is injured
Other

What Does It Stop/Limit You From Doing?*

What Concerns You The Most About Your Problem That Is Making You Consider Physical Therapy?*
(Please select all that apply )

I don’t know what is causing my pain/ problem and how to deal with itDependence on pain medicationGetting short of breath with minimal exertionResuming activity/ exercise after cardiac problemsInability to enjoy leisure activities and maintain my quality of lifeLoss of my mobility and independenceBeing limited in how much I can exercise/stay active or play sportsUrine leakage with coughing, exercise or other strenuous activitiesLosing my balance and history of fallingRisk of possibly having to undergo surgeryOther

The Main Goal That You Would Like To Achieve With Us?*
(Please select all that apply)
Ease my pain/problemImprove my mobility/balance and decrease risk of fallLead an active lifestyleReduce dependence on pain medicationImprove my quality to lifeReturn to enjoying my hobbies/recreational activities with friends and familyLearn to self-manage my problemReduce repeated hospitalization due to chronic heart and lung problemsReturn to prior athletic levelOther

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