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Le Petit Studio Health Questionnaire
How did you hear about Le Petit Studio?
What do you hope to gain from Le Petit Studio?
Do you have any current injuries/aches/pains? Please describe.
Have you ever had a spinal injury?
If Yes, please describe:
Do you have any spinal conditions such as osteoporosis or stenosis?
Have you had joint replacement, partial replacement, or any bone spur procedures? If so, which joints? How long ago was the procedure? Did you follow up with any type of physical therapy?
Have you ever been diagnosed or treated for cancer?
Type of cancer?
Type of surgery/treatment?
How long ago was your treatment?
Have you had any lymph nodes removed? Have you ever been diagnosed with Lymphedema?
Please list any serious or non-serious injuries you may have experienced in your lifetime that might cause irregular movement and affect body balance (i.e. broken ankle, dislocated shoulder, etc.):
Please list any additional surgical procedures you may have had:
Please list any other health concerns along with any medications you may be taking:
Please describe your daily physical activity (i.e. walk to work, sit at computer desk all day, etc.):
Are you now or have you ever been involved in physical activities? (i.e golf, tennis, jogging) If so, please describe:
Are you currently seeking other methods of therapy (i.e. massage, chiropractic, etc.)?
Soho - Midtown
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