Quantum Vitality Body Awareness Questionnaire Order Number Personal Information First Name * Last Name * Email Address * 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 Please be as specific as possible when evaluating the location and level of the discomfort and tension you are experiencing. Affected Area of the Body * Back Neck Hips Shoulders Arms Legs Jaw Head Other Area #1 Detail (check all that apply) * Upper Middle Lower Left Side Right Side Area #1 Level * Area #1 Duration * Constant Intermittent Area #1 Discomfort * Sharp and Stabbing Dull and Achy Pins and Needles Numbness Tightness Affected Area of the Body #2 Back Neck Hips Shoulders Arms Legs Jaw Head Other Area #2 Detail (check all that apply) Upper Middle Lower Left Side Right Side Area #2 Level Area #2 Duration Constant Intermittent Area #2 Discomfort Sharp and Stabbing Dull and Achy Pins and Needles Numbness Tightness Thank you for completing the Quantum Vitality Body Awareness Form. If you have additional areas of discomfort, please complete a second form. Dr. Victoria Moore, DC, MA
