Active Ergonomics®

Congratulations! You have taken the first step towards increasing comfort in your work environment. Active Ergonomics® can provide you with an assessment and education as well as the solution to the problems we detect in your work space. Please take a few moments to fill out the following information and submit it. Once we receive this information we will contact you or your company to schedule your assessment or notify you of a consultant in your area.

NAME:

COMPANY:	POSITION:

ADDRESS1:

ADDRESS2:

CITY,STATE, ZIP:
,
PHONE #:	E-MAIL:

NOTE: Fields marked in RED indicate required information.

Reason For Request:
Choose as many that apply.
	Pregnant
	Above average height or weight
	Recently in a car accident (major or minor)
	Weekend Warrior - moved furniture, sport injury, hobby that caused discomfort
	Recently changed vision prescription or corrective vision type
	Experiencing tingling and numbness in upper extremities
	Post surgical status
	Experiencing chronic headaches or migraines
	Diabetic
	High Blood Pressure
	High Cholesterol
	Traveling for Work and frequent car or plane travel
	Chronic Back Problems
	Tendonitis
	Scoliosis
	Under Chiropractic Care
	Under Physicians care for Physical Therapy
	Other