Patient Screening Tool

Question Title

* 1. Am I currently active, or active before my injury?

Yes

No

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* 2. Do I have an injury or immobility that is limiting me from doing what I want to do on a daily or weekly basis?

Yes

No

Question Title

* 3. Am I willing to learn about my body and put in the work towards making myself better?

Yes

No

Question Title

* 4. Do I currently have goals about my health and my well being that I would like to discuss with Dr. Karla?

Yes

No

Question Title

* 5. Do I want to be pain free and improve your performance and your health?

Yes

No

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* 6. If you answered YES to the majority of the questions above, Elevate Human Potential is a great health care choice for you! If you have any other comments or questions, please leave them below with your contact information and someone will get back to you!