Name First Last Email Address Street Address Cell Phone:Birthday: MM slash DD slash YYYY Sex: Weight: Height: OccupationWhat is your current occupation? Does your occupation require extended periods of sitting? Does your occupation require extended periods of repetitive movements? (If yes, please explain.) Does your occupation require you to wear shoes with a heel (dress shoes)? Does your occupation cause you anxiety (mental stress)? If so, please give a rating of 1 to 10, 1 being minimal stress, 10 being maximal stress. LifestyleDo you partake in any recreational activities (golf, tennis, snowboarding, etc.)? If yes, please explain. Do you have any hobbies (reading, gardening, working on cars, etc.)? If yes, please explain. MedicalHave you ever had any pain or injuries (ankle, knee, hip, back, shoulder, etc.)? If yes, please explain. Have you ever had any surgeries? If yes, please explain. Has a medical doctor ever diagnosed you with a chronic disease, such as coronary heart disease, coronary artery disease, hypertension (high blood pressure), high cholesterol, or diabetes? If yes, please explain. Are you currently taking any medication? If yes, please explain.
