Injury Pain Form

Injury or Pain Form

Injury/Pain Form

Name

First

Date

Are you currently experiencing any pain or discomfort?

Pain

Discomfort

Where does it hurt?

When did it start?

Do you know what caused it, or did it just show up?

What makes the pain feel worse?

What (if anything) makes it feel better?

Have you seen a medical provider about this?

Yes

No

If yes, what was their diagnosis?

. Does this pain limit your ability to perform daily tasks, work, or exercise?

Yes

No

Sometimes

Are there any movements or exercises you’re currently avoiding?

Is there anything specific you’d like me to know so we can train around or rehab this safely?

Would you like me to follow up with:

A movement screen

A corrective exercise plan

A referral to a chiropractor or physical therapist

Just modify training for now

If you are human, leave this field blank.