First Name *

Last Name *

Phone *

Email *

You are about to schedule your free consultation with Kinetic Balance Bliss Postural Alignment Therapist. To better understand your needs and provide you with the best possible advice, please provide an accurate answer to the following questions. Your information will be kept confidential.

Lifestyle and Occupation:

a. What is your current occupation? *

Does your job require long periods of sitting?

Does your job involve physical labor?

b. Describe your typical day in terms of physical activity *

c. Does your health now limit you in these activities? *

Sleep

a. On average, how many hours per night do you sleep? *

b. Do you experience any difficulties falling or staying asleep? *

Exercise and Physical Activity

a. Are you currently engaged in any form of regular exercise? *

b. Do you participate in any form of stretching or yoga? *

Pain and Symptoms:

a. Please indicate where you experience pain or discomfort *

b. When do you typically experience this pain? *

c. Describe the type and duration of the pain. *

Diet and Habits:

a. Are you currently following a specific diet? *

b. Do you smoke? *

c. Are you taking any medications? *

Previous Therapy and Treatment

a. Have you had any postural alignment therapy before? *

b. Have you tried any other forms of therapy or treatment for your pain or symptoms? *

Thank you for taking the time to complete this questionnaire. It will help us tailor our consultation to your specific needs.

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