Physical Therapy Questionnaire - X3 Performance and Physical Therapy

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Nashville, TN
Ft. Myers, FL
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Physical Therapy Services

Physical Therapy Questionnaire

Location interested in:(Required)

Main Reason For Wanting A Physical Therapy Discovery Session *(Required)

Main Reason For Wanting A Physical Therapy Discovery Session *

I’m new to Physical Therapy and not sure what to expect.

I was let down by another healthcare provider in the past and would like see if we are a good fit for each other before I commit.

I’m not yet sure if Physical Therapy can even help me.

I’d like to get an understanding of what’s causing my pain/injury and what you can do to help me before I commit to a full appointment.

It’s just easier to get started this way.

Where Is Your Pain Or Stiffness? *(Required)

What Does It Stop Or Limit You From Doing? *(Required)

What Concerns You Most About Your Pain/Injury That's Making You Consider Physical Therapy? *(Required)

How Long Have You Suffered Or Worried? *(Required)

How Long Have You Suffered Or Worried? *

1-2 Weeks (or less)

2-4 Weeks

1-3 Months

4-1 Months

Over a year

What Is The Main Goal That You Would Like To Achieve With Us? *(Required)

So that we can schedule your Free Discovery Session as soon as possible, please provide us with:

Name(Required)

First Last

Phone(Required)

Email(Required)

Consent(Required)

I agree to the privacy policy.

Ready to Let Us Help You Reach Your Goals?

Whether you’re a weekend warrior or a professional athlete, our unique approach to physical performance will get you there … and beyond.

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May 2022

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Ft. Myers
- 239-313-6109
- greg@x3ppt.com
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Nashville
- 615-988-4550
- monica@x3ppt.com

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