Musician Rehabilitation Questionnaire

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Full Name*

Right or Left Handed?*

Phone*

Email*

Date of Birth*

Primary Physical Therapy Concern:*

What makes it worse?*

What makes it better?*

Pertinent Medical History: (Previous Injury/Diagnosis, Diagnostic Testing, X-Ray, MRI, MD Visits)*

Previous Physical Therapy: Yes/No (Please Elaborate)*

Previous Intervention: (Other than Physical Therapy)*

Primary Instrument: (Genre, Number of Years Played, Hours per day practicing, Hours per week performing)*

Secondary Instrument: (Genre, Number of Years Played, Hours per day practicing, Hours per week performing)*

Other Occupation:*

Leisure Activities:*

Other pertinent information:*

Upload Video Playing Your Instrument:

Drop files here or

Max. file size: 50 MB.

Consent*

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