*1.Your Name/Age(Required.)

*2.Email (for contact)(Required.)

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

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

5.Do you have scoliosis?

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

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

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.

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

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