Suboccipital Tension Assessment Form
Please complete this form to help evaluate your suboccipital tension symptoms and related patterns.
Full Name
*
First Name
Last Name
How would you rate your current suboccipital tension?
*
No tension
0
1
2
3
4
5
6
7
8
9
Severe tension
10
0 is No tension, 10 is Severe tension
How often do you experience suboccipital tension?
*
Rarely
Occasionally
Frequently
Almost always
Which of the following symptoms do you experience along with suboccipital tension? (Select all that apply)
Headache
Neck stiffness
Shoulder discomfort
Visual disturbances
Dizziness
Other
When do you notice your suboccipital tension is worst?
Morning
Afternoon
Evening
No specific time
What typically relieves your suboccipital tension?
Rest
Heat/Cold therapy
Stretching
Medication
Other
Please indicate how much your suboccipital tension interferes with the following activities:
Rows
No interference
Mild
Moderate
Severe
Work or study
1
2
3
4
Physical activity
5
6
7
8
Sleep
9
10
11
12
Social activities
13
14
15
16
How would you describe the quality of your suboccipital tension?
Dull/aching
Sharp
Throbbing
Tightness
Other
Please describe any additional details or patterns you have noticed about your suboccipital tension.
Submit Assessment
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