Program Overview: Thank you for your interest in the Build Better Joints program.  Our array of courses will guide you through eight weeks of curated content, which includes mobility exercises and educational resources designed to not only improve how well you move and feel but to also teach you the WHY each step of the way.

Responses to the following questions will be evaluated to ensure you have no contraindications which could limit your participation and will provide the program facilitators with the needed information to grant you access to your desired course.  Please respond as honestly and accurately as you can.  

The data obtained in this questionnaire will allow for aggregate reporting about the Build Better Joints program and for research and advancement of the Motion Health program.  Data obtained will be stored in a secured Cerner database.

Reach out to Rebekah.grube@cerner.com or David.albersiii@cerner.com with questions or concerns.

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* 1. Name

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* 2. Cerner Email Address

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* 3. Associate ID

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* 4. Gender

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* 5. Age

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* 6. Which course are you signing up for? Select only one.

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* 7. What is your primary reason for signing up for the program? Select all that apply.

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* 8. Are you currently experiencing any of the following symptoms? Select all that apply.

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* 9. How would you rate your average level of stiffness/tightness? 0 being none, 1 being very minimal and barely noticeable and 10 being extremely stiff/tight, limiting your ability to perform activities of daily living.

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* 10. How would you rate your average level of pain? 0 being none, 1 being minimal and barely noticeable and 10 being the worst pain you've ever experienced.

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* 11. Within the past two years, have you had any of the following diagnostic tests for the area of the body of the course you are enrolling in?

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* 12. Are you currently taking any medication for musculoskeletal pain (even non-prescription, over-the-counter)?

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* 13. Do you currently seek regular care by a chiropractor, physical therapist, pain specialist or massage therapist for your musculoskeletal health?

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* 14. Do you have any past or current conditions which would limit your ability to complete a routine of mobility exercises every day?

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* 15. How did you first hear about the program?

Thank you! We will review your responses and contact you within 72 hours to provide you with next steps.

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* 16. Injury Assumption of Risk, Release of Claims, Indemnity Agreement & Permissions
I, the above-named associate, am eighteen years of age or older.  I acknowledge that participation in Build Better Joints, including but not limited to the lower back program, is voluntary.  Furthermore, I acknowledge that participation may expose me to hazards or risks that may result in personal injury and I understand and appreciate the nature of such risks.

In consideration of my participation in the described program under the auspices of Build Better Joints at Cerner Corporation (“Cerner”), I hereby accept all risk to my health and of my injury that may result from such participation.  I hereby release the above named representatives, estate, heirs, next of kin and assigns for any and all claims and causes of action for loss of or damage to my property and for any and all injury to my person, including my death, that may result from or occur during my participation, whether caused by negligence of Cerner, its executive board, officers, associates or representatives, or otherwise.  I further agree to indemnify and hold harmless Cerner and its executive board, officers, associates or representative from liability for the injury or death of any person(s) and damage to property that may result from my negligence or intentional act or omission while participating in the program.

I grant permission for the Motion Health team to use the data obtained in this questionnaire for aggregate reporting about the Build Better Joints program and for research and advancement of the Motion Health program.

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* 17. Please select the box below

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* 18. Associate Signature

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* 19. Date

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