Wellness Assessment
OsteoStrong Torrance
20056 Hawthorne Blvd, Torrance, CA 90503
OsteoStrong Wellness Assessment
First Name
Last Name
Email
*
Phone
*
Date of birth
What OsteoStrong benefits do you desire? (check all that apply)
*
Increase Bone Density
Increase Muscular Strength
Increase Energy
Eliminate / Reduce Joint & Back Pain
Strengthen Immune System
Improve Balance & Agility
Improve Posture
Improve Blood Glucose Levels
Injury Prevention
Improve Athletic Performance
Do you regularly experience pain in any of these areas? (check all that apply)
Lower Back Pain
Mid or Upper Back Pain
Neck Pain
Hip Pain
Knee Pain
Elbow Pain
Shoulder Pain
Wrist Pain
Ankle Pain
Other
On a scale of 1-10, please describe the severity of any painful areas you selected (1 = mild pain, 5 = moderate pain, 10 = severe pain)
What are your current health goals?
How committed are you to achieving these goals?
0
1
2
3
4
5
6
7
8
9
10
What activities do you enjoy?
What obstacles or limitations hold you back from enjoying more of your favorite activities?
What have you tried to do to eliminate these obstacles and limitations?
What are you sacrificing by not fixing this?
How would your life improve if you no longer had these obstacles & limitations?
What would you consider a success?