ARPwave Strength Training Evaluation Form

* Indicates required field

Who Referred You? *

Name *

First

Last

Phone Number *

Phone Number (secondary) *

Email *

Address *

Line 1

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City

State

Zip Code

Country

Date of Birth *

Gender *

School/Employment Status *

Your Physician's Name *

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Last

Physician's Phone Number *

Please answer the following:

Are you Pregnant? Y/N *

Which activities bother you the most? *

Rate your Pain/Weakness on a 1-10 scale *

Are you being treated for Cancer? Y/N *

Please list ALL diagnostic tests performed by any Doctors including X-Ray, MRI, Lab Work, Functional Testing, Psychological Testing, Electrodiagnostics or others. *

When did your symptoms begin? *

Test Results (if any) *

Please list ALL treatments you have had including Rest/Ice/Compression, Physical Therapy, Medication, Surgery, Chiropractic, Massage, Alternative or others *

Are you using a Pacemaker or ICD? Y/N *

Are you on Medication or have a history of Blood Clots? Y/N *

Truthful Representation:
Upon selecting the following box stating "ALL INFORMATION IS TRUE" I hereby state that all the information I have provided is true, correct and complete. If more information about my condition becomes known, I will tell My Back and Body Clinic as soon as possible so that it can be added to my record:

ALL INFORMATION IS TRUE *

Yes

Describe your weakness/injury/symptoms *

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What Readers Are Saying about

'Sick & Tired of Being Sick & Tired:
Solutions for a
Better, Healthier Life'

Amazon Review: 5.0 out of 5 stars- Inspirational read!
Just read this book over Thanksgiving and got so much out of it, it got added to my list of things to be grateful for. I really liked Russell Jones’ down to earth style of writing: relaxed, playful, irreverent but also serious as a heart attack!
I thought I was going to read a book about physical strength but got a whole lot more. With humor (and occasional derision), he writes and models a way of living that touches on everything from how to eat, supplement and maximize our bodies (whether training or rehabbing), to the larger issues of attitude, integrity, relationship to the environment, living and eating as our bodies were intended, setting goals by going inward and really assessing who you are and want to be, and more....
Jones is wholistic, comprehensive, very informative, fun and so positive and grounded. I feel truly inspired. Highly recommend!

​ARPwave Strength Training Evaluation Form

What Readers Are Saying about​'Sick & Tired of Being Sick & Tired:Solutions for a ​Better, Healthier Life'

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ARPwave Strength Training Evaluation Form

What Readers Are Saying about

'Sick & Tired of Being Sick & Tired:
Solutions for a
Better, Healthier Life'