CHOOSE A HEALTH PATH

This questionnaire is about your daily life and the effects on the body's health.

 

 

How to fill out the Questionnaire?

Use one word below to describe your mobility and consistency in these activities.

Most people with muscle pain, trigger point "knot" sensitivity, stiffness or stress will find it difficult to perform some or all of these activities. Choose one word to respond to each activity that best describes your current condition. Once answered, refer to the list below for your Health Path and estimated time to schedule your next service.

   

 Easy          Minimal             Somewhat             fairly           Very             Unable

 

Question 1:  

Easy   Minimal   Somewhat   Fairly    Very    Unable

  • getting out of bed? 

 

  • standing for 20-30 minutes straight?

 

  • walking up one flight of stairs?

 

  • bending down to tie shoes?

 

  • sleep through the night? Fairly 5x a week (example)

 

  • riding in a car for an hour?

 

  • making your bed?

 

  • walking a block?

 

  • turning over in bed?

 

  • walk a few miles? 

 

  • carrying 2 groceries bag?

 

  • sitting in a chair for several hours?

 

  • pulling/pushing heavy doors?

 

  • reaching up to high shelves?

 

  • move a chair?

 

  • lift and carry suitcase?

 

  • lift and support backpack/ pocketbook?

 

  • taking food out of the refrigerator?

 

  • throw a ball?

 

  • putting on pantyhose or socks?

Extra Questions!

knowing what your fitness and stress level are can determine how self-aware you are.  

(number of times) 1-2      3-4      5-6      7-8      9-more  

  • How many times a week do you perform a full body work out? 

 

  • How many times a week do you perform a focused half body work out?   

 

  • How many times a week do you stretch before your workout?

 

  • How many times a week do you stretch after your workout? 

 

  • How many times a day do you eat full meals?  

 

  • How many times a day do you drink a full glass/bottles of water?

 

  • How many times a week do you have time for yourself to mentally de-stress?