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Name *

First Name

Last Name

Phone

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How often do you experience stress or anxiety symptoms (e.g., tight shoulders, low back tension)?

Rarely

Occassionally

Frequently

Almost Always

How well do you sleep at night?

Very Well

Fairly Well

Poorly

Very Poorly

Are you familiar with "self-care"? If so, how do you practice self-care? (Select all that apply)

Mindfulness

Meditation

Exercise

Healthy Eating

Rest and Relaxation

Other

How often do you engage in self-care practices (e.g., mindfulness, meditation, exercise)?

Regularly

Sometimes

Rarely

Never

Have you experienced any recent injuries (e.g., TMJ, tendonitis, low back pain)?

Yes, within the past month

Yes, within the past year

No, but I have mild discomfort

No, no recent injuries

Are you currently experiencing pain? If so, how long have you been feeling it?

No current pain

Yes, occasional pain, but not consistent

Yes, I have had pain for 3 months or less

Yes, I have had pain for the last 6 months or more