Your First Name
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Your Last Name
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Age
13- 80 yrs. old inclusive range
13- 80 yrs. old inclusive range
Gender
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Date of Birth
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Do you have a referring doctor?
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Referring Doctor
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Your E-mail Address
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Contact Number
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Do you have an existing diagnosis?
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Diagnosis
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Chief Complaint
  • - select an option -
  • neck pain
  • shoulder pain
  • elbow pain
  • back pain
  • hip pain
  • knee pain
  • ankle pain
  • general fitness
  • NA
- select an option -
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Pain scale (on a scale of 1-10 with 10 being the highest, how much pain are you in right now?):
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What triggers or increases the pain?
  • - select an option -
  • Daily Activities
  • Sports
  • NA
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What helps lessen the pain?
  • - select an option -
  • Oral or topical medication
  • Certain movements
  • Others
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Goals (what would you like to achieve?)
  • - select an option -
  • Pain management
  • General fitness
  • Improve athletic perfomance
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Past Medical History
  • - select an option -
  • Hypertension
  • Diabetes
  • Cancer
  • Gout
  • Surgery
  • NA
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Exercise Experience/ Fitness Level
  • - select an option -
  • Sedentary
  • Occasional physical activity
  • Regular Exercise
  • Competitive athlete
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Information gathered here will help the Halcyon Fitness team 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?)
  • - select an option -
  • None
  • 1/week
  • 2-3x/week
  • >3x/week
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Exercise preference
  • - select an option -
  • Bodyweight thraining
  • Weight training
  • Yoga
  • Pilates
  • Cardio
- select an option -
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Please note that there may be possible limitations to the delivery of Halcyon Fitness online services, such as:

Video sessions may not be 100% the same as face-to-face sessions.
There may be connectivity or technical issues that may affect the quality of the sessions.
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