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Please fill out all of the fields below. Feel free to indulge into as much detail about your injury as possible. The more you tell me, the more I can help you. *(All personal and medical information is kept confidential)
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The field marked with (*) are required fields.
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Please enter your name and email address.
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Age/ Sex/ Location
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Briefly describe a typical day at work.
(Do you sit most of the day? Are you on your feet all day?)
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Body Part:
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Right /Left or Both:
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How long have you had this injury?
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What type of pain is it? (sharp, dull ache, etc.)
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When do you have this pain? (all the time, day, night, etc.)
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Is the pain constant or intermittent?
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What activities exacerbate your symptoms?
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What activities reduce your symptoms?
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Have you done anything to manage/treat this injury? If "yes", explain.
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Have you ever injured this body part before? If "yes", explain.
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Did you hear any noises (popping/snapping) when you were injured?
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Do you have any numbness, reduced sensation or burning sensations in the injured area or any other area? If "yes", explain in detail.
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Do you have any muscular weakness in the injured area?
Do you have trouble moving the injured area?
If "yes" to either question, explain in detail.
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Is there anything else you would like to tell me about your injury? (Include all related athletic injuries and treatments.)
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How were you referred to this site? If you were referred by a coach, please give me their name and your team/organization name as well.
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