Ascent Physical Therapy Inquiry Form
Getting to know you while you get to know how we can better serve your needs
How Did You Hear About Us?
Which need best fits you?
I am in pain and want to know more about how you can help me
I am an athlete (endurance athlete/triathlete/runner/cyclist, etc) who wants to continue to my next PR pain/injury free
I am an active adult who would like to know more about stay lifelong healthy
I am an adult who has not been as active as I feel I should be and want to make a change
What Service(s) Are You Inquiring About?
3D Printed Orthotics
Year Plan of Care
Medical Bike Fitting
Functional/Weight Lifting Assessments
How long has this been going on for?
It just happened - only a few days ago
A few weeks
A few months
Over the course of a year or more
Not really a problem - I am just looking for more information
How is this problem impacting your life?
I can't do certain things I love to do
I am avoiding activity and not pushing myself because I am unsure if it is safe to
I am doing everything - it just hurts or it is annoying
It is not impacting my life yet but I am concerned it might in the future
I am not sure - I just want to speak to an expert about it
What made you decide to fill out this form?
Why did you decide now vs. before (days,weeks, months) to reach out and address your needs?
On a Scale of 0-10 (0 being not teachable at all and 10 being "I am the best learner"), how teachable are you?
On a Scale of 0-10 (0 being no coachable at all and 10 being "I follow everything to a T"), how coachable are you? (yes there is a difference between this and the one above
How do you best learn?
See and then do
I like to act things out
Before reaching out through this form, what have you tried in the past to address your needs?
What value would us helping you bring to your life?
Not much - I am doing fine - Just want more information
Some value - It is not that bad
Amazing value - I am in pain and would like for this to be gone
Exceptional value - I am avoiding doing the things I live and it really sucks
Priceless - if what I have is gone despite everything I have tried - it would be AMAZING!!!
What, in your mind, is your best absolute outcome from what you want to address?
What would you wish to learn?
How to get out of pain?
Get rid of nagging aches
How to prevent and stay injury free?
How to live life healthy and strong as you age
How to achieve your next PR (personal record)
How to improve your mechanics/efficiency during activity?
When is the best time to contact you?
Do you prefer us contact you through phone call or email?
Besides taking care of your concerns, what other services would you be interested in learning more about?
Massage therapy/Sports/Recovery Massages
Running Mechanics Assessments
Is there anything else you would like us to know or add?
Please verify that you are human
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