Health Intake Pre-screening Form
Blood Clots/ or Blood Disorders?
Peripheral Artery Disease? If yes, are you currently receiving "best medical therapy": anti-platelet and statin medication?
Heart problems?
Neurologic disorders, If yes, please list
Tumors, If yes where?
Lung problems?
Tennis/Golfers Elbow?
Tendinopathy? If so, where?
ANY recent or ongoing infection?
Recent injury If yes, what injury & how long ago?
Stress Urinary Incontinence (SUI)?
Chronic Pelvic Pain Syndrome (CPPS)?