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* 1. Your Name/Age

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* 2. Email (for contact)

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* 3. Where are you feeling pain? Please elaborate as much as possible.

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* 4. Do you have a rounded upper back/forward head carriage (hyper-kyphosis)?

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* 5. Do you have scoliosis?

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* 6. Do you have any bone density issues, such as osteoporosis?

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* 7. Any other structural issues we need to be aware of like herniated or Bulging discs? Spondylolisthesis? Arthritis? Stenosis?

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* 8. Have you been in any accidents, even from many years ago? Any serious falls, or whiplash ? If yes, please explain the incident, if you are able.

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* 9. Do you feel numbness or get tingling sensations anywhere in your body? If yes, please explain.

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* 10. Do you currently do any type of exercise? If so, what kind? How many times a week?

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