SLIDING SCALE SIGN-UP FORM Name * First Name Last Name Email * Date of Birth * MM DD YYYY Please list what class or session you are signing up for. * Please describe in your own words what is giving you trouble and how it all started. If it is pain, when is it the worst? In a 24-hour period, tell me the activities that irritate the problem. What is the activity that makes it feel the best? If it is not being active that makes it feel better, tell me in detail what that is. Example: lying down, hot bath, hot tub etc. What do you do in a day? Do you sit all day, work outside, or a mixture of both? What is your activity level other than your daily movements? (Hiking, skiing, walking, yoga etc.) How often do you do your workouts? Are you comfortable doing your workouts? Do you hurt later after you have been exercising? Summarize your number one complaint and any activity that it keeps you from doing. Thank you!
