KINETIC
Initial Recovery Assessment
Complete this assessment to help us create your personalized recovery plan
Personal Information
First Name
Last Name
Email
Phone Number
Age
Gender
Select gender
Height (cm)
Medical Condition
Primary Condition
Select your condition
How long have you had this condition?
Select duration
Please describe your condition in detail
Pain Level (0 = No Pain, 10 = Worst Pain)
0
1
2
3
4
5
6
7
8
9
10
Medical History
Do you have any of the following conditions? (Select all that apply)
Diabetes
Heart Disease
High Blood Pressure
Arthritis
Osteoporosis
Asthma
Previous Surgery
Chronic Pain
Current Medications
Recovery Goals
What are your primary goals for recovery? (Select all that apply)
Pain Reduction
Improved Mobility
Return to Sports
Perform Daily Activities
Prevent Future Injuries
Improve Strength
Improve Balance
Prepare for Surgery
Specific Goals
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