Welcome to the first step toward total health, wellness and living pain free. Please complete the following confidential questionnaire. Only Symmetry staff will view and assess your answers for the purpose of creating an overview of health and wellness in your workplace. Please answer all questions open, honestly and to the best of your ability.

Name *
Name
Phone *
Phone
Date of Birth *
Date of Birth
Have you ever been injured on the job?
Are you currently suffer with an injury?
Do you struggle with headaches?
Do you struggle with sprains?
Do you struggle with body strains or tension?
Do you struggle with fatigue?
Do you have trouble sleeping?
Do you have frequent muscle fatigue or soreness?
Do you have issues with indigestion?
Do you have numbness in fingers or toes?
Do you have hip pain?
Do you have shoulder pain?
Do you have back pain?
Do you have the sensation of pins and needles in your arms
Do you have the sensation of pins and needles in your legs?
Do you have foot or ankle pain?
Do you have trouble lifting or moving objects?
Do you have trouble bending over?
Do you have loss of balance?
Do you struggle with depression?
I have excellent endurance or aerobic capacity.
I have excellent endurance or aerobic capacity.
How much do you agree with this statement.
I have chronic physical issues.
I have chronic physical issues.
How much do you agree with this statement.
I understand the causes of my chronic physical problems.
I understand the causes of my chronic physical problems.
Choose the option that applies.
Have you ever tried physical therapy?
My current health care provider is great and I receive the best care.
My current health care provider is great and I receive the best care.
How much do you agree with this statement?
Are you open to alternative methods of care?