Wellness Assessment
First Name
*
Last Name
*
Email
*
Height
*
Weight
*
Were you referred to us by your Doctor?
*
Yes
No
Doctors you are currently seeing (First and Last Name):
Birthday (YYYY-MM-DD)
Mailing Address
City
State
Zip Code
Occupation
How did you hear about OsteoStrong?
Facebook
Friends/Family
Instagram
Doctor Referral
Tony Robbins
Podcast
Walk-In
Google/Online Search
X3 - John Jaquish
Corporate Lead
Other
Who were you referred by?
Which of these OsteoStrong benefits interest you most?
Bone Density, Osteoporosis, Osteopenia
Back Pain
Knee Pain
Type 2 Diabetes
Posture, Balance and Agility
Athletic Performance
Injury and Fracture Prevention
Joint Pain (Tendon and Ligament Strength)
Physical Strength
Energy and Vitality
Overall Health & Wellness
What type of physical activity do you currently participate in?
Walking
Running
Weight Bearing Exercise
Yoga
Pilates
Hiking
Cycling
Bootcamp
What Vitamins/Supplements are you currently taking?
Vitamin D3
Calcium
Vitamin K2
Magnesium
B Vitamins
Probiotics
Bone Support Multivitamin
Protein/Collagen
What medications are you currently taking?
Prolia
Fosamax
Forteo
Boniva
Reclast/Tymlos
Calcitonin
Metformin / Insulin
Synthroid
Levothyroxine
Blood Pressure
Pain - Cortisone, Gabapentin, etc..
Acid Reflux or Gerd (Prilosec, Omeprazole, etc...)
Have you had a Bone Density scan?
Yes
No
If Yes, what was the last scan date? T-Score? Where was this completed?
Previous Dexa-Scan Date
Were you diagnosed with Osteoporosis or Osteopenia?
Yes
No
I Don't Know
Have you lost any height?
Yes
No
If yes to lost height, how much?
0-1 inch
1-2 inches
2-4 inches
5+ Inches
Do any of the following apply to you? (Check all that apply)
Muscular Dystrophy
Unmedicated Hypertension
Third Trimester Pregnancy
Active Hernia
Do you have any of the following conditions? (Check all that apply)
Premature Menopause
Low Levels of Testosterone
Celiac/IBD disease
Rheumatoid Arthritis
Osteoarthritis
Scoliosis
Diabetes
Multiple Sclerosis
Parkinson's
Fibromyalgia
Vertigo/Dizziness
Fainting
Cancer
Heart Disease
Stroke
Blood Disorder
Hypo/Hyperthyroid
Seizures/Epilepsy
Do you or your doctor have any concerns about any medical conditions that would interfere with you engaging in an exercise program?
Yes
No
If yes, please explain
Do you have any recent or existing medical procedures, surgeries, sprains, broken bones, or muscle conditions that would prohibit you from physical activity?
Yes
No
If yes, please explain
I'd like Osteostrong to keep my physician up to date with my progress.
*
Yes
No
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.
*
Yes
Full Name
Date (YYYY-MM-DD)
COMPLETE WELLNESS ASSESSMENT