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TherHab Fitness Wellness Questionnaire

First Name

Last Name

Please fill out the following form to help us understand your physical condition.

Email Address

Date of Birth

I am intereted in learning more about

Online Wellness and Fitness Assessment

Live Zoom Classes

Video Library

Finding a TherHab Fitness Proviider near me

Attending Classes in a Licensed TherHab Fitness Facility

Individual Physical Therapy

Individual Occupational Therapy

Other

Please list significant past medical history.

Diabetes

Difficulty Sleeping

History of Falling

High Blood Pressure

Arthritis

Stroke

Osteoporosis

Heart Disease

Joint Replacement

Cancer

Lung Disease

Syncope

Use of an assistive device

Chronic neck or back pain

Other

If you answered yes to any question, please elaborate.

Please state your wellness goals and past exercise experience.

Signature

Today's Date

I declare that the info I’ve provided is accurate & complete.I understand that TherHab Fitness is required to maintain the privacy of my health information in accordance with the terms of its HIPAA Privacy Notice. I further acknowledge that I can receive a copy of the current HIPPA Privacy Notice at any time. I understand that TherHab Fitness restricts its uses and disclosures of my health information for physical therapy treatment, health care operations and participation in Live Zoom Classes. By signing this form, I consent to the Practice's use and disclosure of my health information for treatment, participation in Zoom Videos, and health care operations.

HomeTherHabFit

100 Allawood Court, Suite110

Simpsonville SC 29681

864-525-2654