General Health Questionnaire

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* 1. I am generally a healthy person.

Yes

I don't know

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* 2. I am happy with my body weight.

Yes

I don't know

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* 3. I am active and workout (i.e. walking, running, gym, fitness classes).

1-2x/month

1x/week

2-3x/week

>4 times per week

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* 4. My favorite way to exercise is:

Running

Walking

Riding my bike

Fitness Classes; HITT

Lifting weights

Dancing/ Zumba

Crossfit

Kickboxing

Yoga/ Pialtes

Other

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* 5. I have pain (constant or intermittently) on a daily basis.

Yes

I don't know

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* 6. I have an injury.

Yes

I do not know

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* 7. I have pain/ discomfort:

Head/ Neck

Shoulder

Arm

Wrist/Hand

Mid Back

Low Back

Hip

Knee

Foot

No pain or concerns

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* 8. I would like to receive treatment for my concerns, but I don't know where to start.

Yes

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* 9. I would like an email with free information on:

Why I am hurting?

Appropriate Weight & Fitness Prescription

Details about attending Physical Therapy

Have Excelerate call me about my concern

Question Title

* 10. Please Include your information below so we can address your questions and concerns.

Name

City/Town

State/Province

Email Address

Phone Number