Please fill out the following form for your upcoming Happy Back Workshop. In order to get the most use of this information and accommodate your needs in the workshop, please complete it no less than 2 days prior to your event. 

Name *
Name
3. Do you experience any pain or discomfort?
4. Do you have radiating pain?
5. When is your discomfort worst?
Check all that apply
6. Have you ever had any of the following?
Check all that apply
9. Please select the scale that best describes your physical health in the past month.
General Health
Physical Health
Strength
Stamina
Endurance
Flexibility
Range of Motion
Balance
Nutrition
Digestion
Elimination
Exercise Habits
Quality of Sleep
Pain
10. Please select that scale that best describes your emotional well-being this past month.
Breathing
Energy Level
Mood
11. Over the past month, how often are you experiencing the following feelings?
Hopeful
Content
Calm
Relaxed
Focused
Worried
Regretful
Anxious
Depressed