Virtual Movement Nutrition | Honor Your Nutrition

Please answer all questions to help get the most out of your Virtual Movement Screening:

First Name *

Last Name *

Email *

Date of birth *

Gender *

Reason for Screening: *

If other, please explain:

Details

*To make the best use of your time, please be as specific as you can here.

Pain Level (0-10) *

Pain Location: *

When did the pain start? *

What movements or things make the pain worse? *

How long do symptoms last once aggravated? *

What makes it better? *

Unexplained weight loss? *

Yes

No

Fever, chills, or night sweats? *

Yes

No

New or worsening bowel or bladder changes? *

Yes

No

Numbness/tingling? *

Yes

No

If you answered YES to any of those questions, or if your pain is worsening, please notify your therapist or primary care provider.

Please explain:

What movement(s) and/or activity(s) are most effected by your current complaint? *

What are your top 1-3 goals? (does not have to be fitness focused, can be functional) Example: Walk down stairs/carrying (x) pain free *

Do you have access to any equipment? (Please list what you have access to) *

Do you have previous experience with structured exercise programs? *

Is there anything else you’d like me to know?

Virtual MOVEMENT SCREENING