Pain Assessment Form 2025

Let’s Decode What Your Body’s Been Trying to Tell You
This quick check-in helps you understand why your pain lingers and what your next step should be. It’s not a full diagnosis, but it’ll show you what’s likely running in the background. (Takes 2 minutes!)
Today

MonthDayYear
Today
Name*
Date of Birth*

MonthDayYear
Calculated Age
Gender*

FemaleMaleOther
E-mail*
Where did you hear about this form?*

Height (ft) *
Height (in)*
Total Height in Inches
Weight in lbs*
Age
BMI (Body Mass Index).
Calculated Automatically

“Click or tap the image below to mark where you feel symptoms. You may use the following color key or letter codes: Tap or click the image below to mark where you feel symptoms.

S = Sharp pain D = Dull or achy N = Numbness H = Heat/inflammation E = Emotional holding

◼️ S = Sharp pain 🟦 D = Dull or achy 🟩 N = Numbness 🟨 H = Heat/inflammation 💜 E = Emotional holding
Front View - Draw on Image
Rear View - Draw on Image
Left and Right View - Draw on Image

What medicine are you taking? And how often do you take?
eg. Lisinopril 40 mg once per day
What kind of support feels right, right now?*

I just want someone to hear what’s going on.I’d love a custom plan mapped to me.I’m curious—what else can I do naturally?I’m ready to book something if it feels aligned.

You're Almost Done - Here's What Happens Next
Based on your answers, we've uncovered a key pattern your body may be running — one that could be impacting your energy, pain, digestion, or emotional regulation.

⚡ Your personalized Acupoint Activation Guide is almost ready.
💌 It will be delivered to your email shortly along with steps to help reset the pattern and move forward.

This isn’t about managing symptoms, it’s about understanding them at the root. You’ve already started that process.
“Your system may be in Overload.”

Extra weight can often mean your system is trying to buffer — emotionally or energetically. This BMI pattern may reflect long-term inflammation, metabolic strain, or unresolved stress.
This isn’t about shame. It’s about your body storing signals that haven’t had a place to go.
👉 Consider starting with the Anti-Inflammatory Reboot to calm your system before deep work.
Download the Reset Guide
A higher BMI doesn't always mean excess fat.
For some, structural build — like a fuller bust or hips — can elevate BMI without reflecting metabolic imbalance.
We look at patterns, not just numbers, to understand what your body might be buffering or storing.
👉 If your system is holding tension, stagnation, or emotional weight, the next step is to gently restore flow.
Try the Movement + Relief Guide
“Your BMI is in a balanced range.”
This gives us space to decode the deeper patterns — emotional, nervous system, or energetic.
You may still be tired, inflamed, or stuck… but your weight isn’t the story. Your patterns are.
👉 Continue with your recommended guide based on how your body speaks.
“Your system may be under-resourced.”
In Chinese medicine, low body weight often shows up as Qi or blood deficiency.
This means your body might not be holding or storing what it needs to thrive.
👉 Start with core nourishment and reserve-building:
Download the Qi Recharge Guide
You’re showing signs of Qi Deficiency—fatigue, fog, and low reserves are your body’s signal for restoration.
Your pattern reflects excess heat and inflammation—swelling, irritation, and a body that feels on edge or puffy.
You’re experiencing signs of stagnation—symptoms that stay stuck, tension in key areas, and emotional holding.
This looks like a Wind pattern—your nervous system may be oscillating between high alert and collapse.
Your system may be in overload—too many triggers, too fast, creating fatigue, disconnection, or chaotic symptoms.
➡️ Click Next to submit your responses and receive your full results.

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Let’s Decode What Your Body’s Been Trying to Tell You

This quick check-in helps you understand why your pain lingers and what your next step should be. It’s not a full diagnosis, but it’ll show you what’s likely running in the background. (Takes 2 minutes!)

You're Almost Done - Here's What Happens Next