Name*
Email*
Phone
Gender* MaleFemale
Area of the Body Head/JawNeckShoulder (Left)Shoulder (Right)Elbow (Left)Elbow (Right)Hand/Wrist (Left)Hand/Wrist (Right)HipsBack (Upper)Back (Mid)Back (Lower)Legs Hamstrings or QuadsCalves (Left)Calves (Right)Knees (Left)Knee (Right)Feet/Ankle (Left)Feet/Ankle
Sensation DullSharpDiffuseLocalizedSuperficialDeepHotColdElectricalNumbingPainfulCrampingWeakSwollenStiffStingingBurning
When did this physical problem first occur?
Describe any surgeries you have had and the date they occurred
What have you tried that makes you feel better?
What activity do you do that makes it feel worse?
How did you hear about The Total Body Connection?
Additional Comments
