Wellness Assessment
Were you referred to us by your Doctor?*
Which of these OsteoStrong benefits interest you most?
What type of physical activity do you currently participate in?
What Vitamins/Supplements are you currently taking?
What medications are you currently taking?
Have you had a Bone Density scan?
Were you diagnosed with Osteoporosis or Osteopenia?
Have you lost any height?
If yes to lost height, how much?
Do any of the following apply to you? (Check all that apply)
Do you have any of the following conditions? (Check all that apply)
Do you or your doctor have any concerns about any medical conditions that would interfere with you engaging in an exercise program?
Do you have any recent or existing medical procedures, surgeries, sprains, broken bones, or muscle conditions that would prohibit you from physical activity?
I'd like Osteostrong to keep my physician up to date with my progress.*
I assume all responsibilities for my decision to engage in the OsteoStrong program. I will not hold any OsteoStrong center or OsteoStrong Franchising, LLC, the owners principles, partners, agents, affiliates, contractors, employees, parent company or subsidiaries liable or responsible for any physical injuries or mental anguish that I may experience as a result of my participation within the OsteoStrong center. I state that I am physically and mentally capable of using the equipment. If I am a parent or legal guardian signing on behalf of minor, I state that the minor is physically capable of utilizing the OsteoStrong center.*