Connective Tissue and Muscle Assessment
Please complete this assessment to help us understand your connective tissue and muscle health. Your responses will assist in evaluating your symptoms and planning further care.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Date of Birth
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
What is your main reason for seeking this assessment?
*
Please indicate the areas where you are experiencing pain or discomfort.
*
Neck
Shoulders
Back
Arms
Legs
Hips
Other
Rate the intensity of your pain today.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain imaginable
10
0 is No pain, 10 is Worst pain imaginable
Check the symptoms you are currently experiencing.
*
Swelling
Stiffness
Weakness
Limited Range of Motion
Numbness or Tingling
Muscle Spasms
Other
How much do your symptoms interfere with daily activities?
*
Not at all
1
2
3
4
Completely
5
1 is Not at all, 5 is Completely
Please indicate your level of difficulty performing the following activities in the past week.
*
Rows
No difficulty
Mild difficulty
Moderate difficulty
Severe difficulty
Unable to perform
Standing up from a chair
1
2
3
4
5
Walking up stairs
6
7
8
9
10
Lifting objects
11
12
13
14
15
Carrying groceries
16
17
18
19
20
Getting dressed
21
22
23
24
25
Have you had any previous injuries or conditions affecting your connective tissue or muscles?
*
Yes
No
How often do you engage in physical activity or exercise?
Please Select
Daily
Several times a week
Once a week
Rarely
Never
Are you currently taking any medications related to connective tissue or muscle problems? If yes, please list them.
Submit Assessment
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