Consent Form

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Your First NameField is required!Field is required!Your Last NameField is required!Field is required!AgeField is required!Field is required!GenderField is required!Field is required!BirthdateField is required!Field is required!Referring DoctorField is required!Field is required!Your E-mail AddressField is required!Field is required!Contact NumberField is required!Field is required!DiagnosisField is required!Field is required!Chief complaint (Do you have any concern regarding your movement or physical condition? Or What’s your main reason for consulting with us?)Field is required!Field is required!Pain scale (on a scale of 1-10 with 10 being the highest, how much pain are you in right now?)Field is required!Field is required!Aggravating/ relieving factors (what makes the pain worse or what makes it less?)Field is required!Field is required!Goals (What do you want to accomplish? Ex. Lesser pain, be able to run/walk pain-free; specific activities you want to improve)Field is required!Field is required!Past Medical HistoryField is required!Field is required!Exercise Experience/ Fitness LevelField is required!Field is required!

Information gathered here will help the PT gauge and understand the patient’s fitness level and exercise preferences.

Exercise frequency (prior to your injury how often do you exercise in a week?)Field is required!Field is required!Exercise preference (what exercise routines have you tried before? Pilates? Yoga? Weight training?)Field is required!Field is required!

We at Halcyon Fitness want to ensure that you understand the coverage of services and limitations such as:

A video consultation may not be 100% the same as face-to-face training/rehab.There are possible connectivity or technical issues during video consultation that may affect the quality of the sessions. Pictures, videos, and other information may be collected as part of the assessment as long as it is relevant to the sessions.Field is required!Field is required!Submit