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PostureFit enrolment form

Page 1

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Question 1.

Name

- Required.
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Question 2.

Date of birth

- Required.
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Question 3.

Address including postcode

- Required.
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Question 4.

Email

- Required.
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Question 5.

Mobile

- Required.
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Question 6.

Height, weight and shoe size

- Required.
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Question 7.

Current injuries/issues

- Required.
Question 8.

On a scale of 1-10, 1 being No Pain and 10 being Excruciating, where would you mark your current pain levels?

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Question 9.

What treatment have you receive previously for this?

- Required.
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Question 10.

Typical physical activities – work, sport, recreation?

- Required.
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Question 11.

Please give details of any other medical conditions or medication that you feel your practitioner should be aware of.

- Required.
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Question 12.

What outcome would you like to achieve from a PostureFit consultation and treatment?

- Required.
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Question 13.

I understand I am supplying PostureFit with images, personal information, physical injuries, and physical history information for the benefit of my consultation and treatment.
I understand that I should NOT attend my face to face appointment in the event that I am suffering flu like symptoms.
For online consultations - I will ensure I am in a safe environment free from hazards.
I am aware that PostureFit will store my personal data for medical records purposes.

- Required.