Online Form HPRC Physical Therapy Screening Form Name* First Last Date* Date Of Birth* Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Phone*Email* Enter Email Confirm Email Location*Birmingham, ALAuburn, ALColumbus, GAColumbia, SC--Forest DriveColumbia, SC--Killian RoadLexington, SCotherPlease select nearest HPRC locationWhat types of exercise are you currently doing?* Strength Cardio Flexibility Balance Weight Control Other Type of Insurance* Regular Medicare Other Name of Insurance Company (If Regular)What sports or activities are you training for? List any short term or long term goals.*Are you currently experiencing pain with your exercise program?* Yes No Explain Yes answers to above questionAre you currently receiving medical treatment for any musculoskeletal condition?* Yes No If the answer to the above question is yes, please explain.Have you had previous injury to any of the following? Head/neck Lower back Shoulder Elbow/hand/wrist Hip/Thigh Knee Foot/ankle Explain any checked answers above. Include date(s) if applicable.Family Physician:
