Date MM slash DD slash YYYY Player Information:Player's Name:(Required) First Last Player's Email Player Date of Birth:(Required) MM slash DD slash YYYY Player Age:(Required)Does the player have a phone?(Required) Yes No Player Phone Number:About the Player:Classification: 9u 10u 11u 12u 13u 14u Junior High High School College Professional Skill Level: A AA AAA Major Primary Position: Pitcher Infield Outfield Catcher Secondary Position: Pitcher Infield Outfield Catcher Do you play catcher? Yes No Throwing Arm: Right Left Current Team:Previous Team:Are you receiving pitching lessons or training? Yes No Who is your current pitching coach?Parent Information:Parent's Name(Required) First Last Parent's Email(Required) Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Parent's Phone Number:(Required)Communication Preferences:Which email should the exam results be delivered to?(Required) Player's email Parent's email Who should we send a reminder about the appointment to?(Required) Player Parent Medical Screening:Has your doctor ever said that the player has a heart condition and that he/she should only do physical activity recommended by a doctor?(Required) Yes No Do you ever feel pain in your chest when you do physical activity?(Required) Yes No In the past month, have you had chest pain when you were not doing physical activity?(Required) Yes No Do you have a bone or joint problem that could be made worse by a change in your physical activity?(Required) Yes No Have you ever had an elbow or shoulder injury that required medical attention?(Required) Yes No Do you lose your balance because of dizziness or do you ever lose consciousness?(Required) Yes No Is your doctor currently prescribing drugs for your blood pressure or heart condition?(Required) Yes No If you answered yes to any of the above questions please give us more information about the reason you answered yes:Is there anything else we should know about the player to help with the evaluation?Assessment by Reliant Physical TherapyInitial Assessment or Reassesement Price: ArmCare AppWould you like to be trained on the ArmCare App?(Required) Yes No Recommended if you plan to purchase the ArmCare assessment package to use away from the clinic to monitor your strength. ArmCare Subscription Level If you would like to get the most out of the app you will need a premium subscription with ArmCare.com and an ArmCare Assessment Package (sold separately at ArmCare.com). Would you like the Basic or Premium Subscription(Required) Basic Version Premium Version ArmCare Assessment Package Click to View Use code ReliantPT to get 10% off Premium v/s Basic Subscription ConsentConsent and Acknowledgement:(Required) Reliant PT's ArmCare Program is a monitoring program designed to reduce the risk of injury. I understand that there is an inherit risk of injury with any sport and it is impossible to guarantee that injury will not occur no matter how much we intervene to mitigate risk factors. I consent for my examination results to be discussed with my current pitching coach. The success of the players ArmCare program will be highly dependent on his/her compliance with the daily training and consistency of testing his arm. I understand that there are risks involved in any examination and/or exercise program. I agree that I assume this risk and release Reliant, Inc. and it's representatives from any and all liability or injury. Signature(Required)Total
