Body Awareness Questionnaire

    Personal Information

    What is Your Current Level of Discomfort?

    Please indicate where in your body and the current level of tension or discomfort you are experiencing and where you feel it using the following scale:

    Discomfort Level: Normal 0-1; Mild 2-4; Moderate 5-7;Severe 8-10

    Constant (C) or Intermittent (I)

    Nature of Discomfort: Sharp and Stabbing; Dull and Achy; Pin and Needles; Numbness; Tightness

    Quantum Vitality Body Awareness Diagram

    Please be as specific as possible when evaluating the location and level of the discomfort and tension you are experiencing.

    Affected Areas of the Body

    Choose Area #1 (required)

    Area #1 Detail - check all that apply

    Discomfort - check all that apply:

    Level - Rate intensity from 1-10

    Duration (choose Constant or Intermittent)

    Choose Area #2

    Area #2 Detail - check all that apply

    Discomfort - check all that apply:

    Level - Rate intensity from 1-10

    Duration (choose Constant or Intermittent)

    Choose Area #3

    Area #3 Detail - check all that apply

    Discomfort - check all that apply:

    Level - Rate intensity from 1-10

    Duration (choose Constant or Intermittent)

    Thank you for completing the Quantum Vitality Body Awareness Questionnaire!

    MENU