*Will this be your first time working with an RCPT Professional? Yes No
Has a doctor ever told you that you have a heart condition and you should only perform exercise as recommended by a doctor?
Do you ever feel pain in your chest when performing physical activity? Yes No
Have you experienced chest pain while performing physical activity within the past month? Yes No
Do you ever lose consciousness, or lose your balance becase of dizziness? Yes No
Do you have a bone or joint problem (ie. back, knee, hip) that could be made worse by your change in physical activity? Yes No
Are you currently taking any prescribed medications? Yes No
Are there any other reasons (other than acute laziness :-) ) you believe you should not perform physical activity? Yes No
What Days of the week work best for you?
What time of day works best for you? --No Preference-- Early Morning (5:30-8am) Morning (8am-11am) Early Afternoon (11am-2pm) Afternoon (2pm-5pm) Evening (5pm-9pm) Would you like for us to keep your credit card on file for future purchases? Yes No
Additional Comments (ie. list of medications, injuries, aches & pains)
Our world class professionals possess the proficiencies to help you optimize your human function.Request an Appointment to get started.
