Follow Up! -

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?

Who were you referred by?

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 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)