FormsCenter: Intake PAR Q/Health Questionnaire Service Info and Policies Center: Session Records Functional Movement Evaluation Functional Movement Evaluation Name * First Name Last Name Email * Pain/Stiffness Area/Intensity and Description * Posture/Gait SFMA Local Mobility Screen FMS Thank you! Prescription Pad/Session Notes Center: Agreement Program Agreement Program Agreement Name * First Name Last Name Email * Service * MyACT (solo) IMR Full (IMR w/ MyACT) Frequency (x/wk) * 1x/wk 2x/wk 3x/wk Number of Weeks in Program * Time frame for program to last # of Sessions in Program * 3 6 9 12 Expiration Date * In order to keep a time frame for which a strategy can be effective, an expiration of 2 weeks past the intended length of the program is set. All appointments expire after this date. MM DD YYYY Price per appointment * Total Price for Program * Additional Notes * Name (as signature) * I agree First Name Last Name Thank you! Remote Nutrition Questionnaire Consultation Report Card Nutrition Questionnaire Forms Form Name * First Name Last Name Email * How many times/day do you eat on average? * 1x 2x 3x 4x 5x more or 'throughout the day' How many grams of protein do you consume per day? skip if unsure How many servings of vegetables and fruits do you eat per day? skip if unsure Give a general description of your common breakfast just basic food examples and categories Lunch (or meal 2) Dinner (or meal 3) Thank you!
