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Urja Assessment Form

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Specify movement restricted:
Walking
Running
Sleeping
Any Other
Do you suffer from any pain?
Neck Pain
Back-Ache
Shoulder-Pain
Elbow Pain
Wrist-Pain
Leg-Pain
Ankle Pain
Severity of pain?
0
1
2
3
4
5
6
7
8
9
10
What sport (s) do you participate in?
Tennis
Cricket
Roller Skating
Badminton
BasketBall
Football
Hockey
Golf
Swimming
Running
Gymnastics
Dance
Yoga
Others
Please state the nature of your participation:
Recreational (Gym)
Competitive
Amateur
Professional
Do you wish to consult our doctor for:
Your Health Status And Prevention Of Injury
Advice & Treatment
Nothing
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