Test Form

Is Flow Therapy Right for You?

This one-minute self assessment form will provide us with the information we need to evaluate if Flow Therapy is right for you. Upon submitting your information, you can expect a call from a friendly team member to talk through their evaluation. They can answer questions about the treatment, can discuss insurance coverage, and can even help you get started with treatment!

Select all of the symptoms affecting you to begin a one-minute self-evaluation.
*
- Chest Pain
- Shortness of Breath
- Fatigue
- Pain in Jaw, Shoulder, Arm, Back or Above the Stomach

Do you ever experience these symptoms when walking 1 or 2 blocks on level ground or climbing a flight of stairs at a normal pace?
Do you ever experience these symptoms when walking 1 or 2 blocks on level ground or climbing a flight of stairs at a normal pace?*
- Yes
- No

Do you feel these symptoms limit activities associated with daily living, such as household chores, shopping, or leisure?
Do you feel these symptoms limit activities associated with daily living, such as household chores, shopping, or leisure?*
- Yes
- No

Do you ever get these symptoms while resting, after eating, or just watching television?
Do you ever get these symptoms while resting, after eating, or just watching television?*
- Yes
- No

Have you decreased your activity in the past 6 months due to these symptoms?
Have you decreased your activity in the past 6 months due to these symptoms?*
- Yes
- No

Do you take nitroglycerin tablets before certain activities to prevent these symptoms?
Do you take nitroglycerin tablets before certain activities to prevent these symptoms?*
- Yes
- No

Are you dissatisfied with your current quality of life because of lack of energy, symptoms, or inability to engage in your normal activities of daily living?
Are you dissatisfied with your current quality of life because of lack of energy, symptoms, or inability to engage in your normal activities of daily living?*
- Yes
- No

Get Your Results

Fill out the form below to receive your report via email.
First Name*

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Last Name*

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Phone Number*
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Email Address

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City, State*

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Cardiologist’s Name

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Cardiologist’s Email Address

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Consent*
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