How should we address you?
First name
ORIGIN & DURATION OF SYMPTOMS
1. How did your symptoms first begin?
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After a clear injury or illness (e.g. car accident, surgery, infection)
Suddenly, with no physical explanation
During a stressful life change or emotional event (grief, burnout, divorce, job loss, etc.)
I’m not sure, there wasn’t an obvious cause
2. How long have you been experiencing these symptoms?
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Less than 3 months
3–6 months
Over 6 months
Years, it’s become part of my identity/life
3. Did your symptoms begin or worsen during a period of emotional stress—even if it didn’t feel directly connected at the time?
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Yes – I was going through something emotionally difficult like burnout, grief, a breakup, financial stress, or overwhelm
Yes – but it was a “positive” life change like getting married, having a baby, starting a new job, or moving homes. It felt exciting, but also brought a lot of pressure, responsibility, or emotional load
Maybe – I didn’t realize it at the time, but looking back, there was a lot going on emotionally or mentally
No – there was nothing particularly emotional or stressful happening
4. Have serious medical conditions (like cancer, autoimmune disease, or organ damage) been reasonably ruled out by your healthcare providers?
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Yes – my doctor(s) have ruled out anything serious or dangerous
Mostly – I’ve had some testing and nothing major was found
No – I haven’t had tests or I’m still waiting on results
I’m not sure
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SYMPTOM MAPPING & BEHAVIOR
5. Where do you currently experience pain or chronic symptoms? (Check all that apply)
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Headaches or migraines
Neck or shoulder pain
Back pain (upper, mid, or lower)
Pelvic pain or menstrual pain
Joint pain (hips, knees, wrists, etc.)
Digestive issues (IBS, bloating, nausea)
Fatigue or burnout
Tingling, numbness, or strange sensations
Anxiety, dizziness, or chest tightness
Other
Q5 Score
6. Do your symptoms affect more than one part of your body or move around?
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Yes – I have pain or symptoms in multiple areas or both sides of my body
Yes – the symptoms move or have shifted over time
Somewhat – I’ve had different issues pop up, but didn’t think they were related
No – it’s stayed in one place consistently
7. Do your symptoms fluctuate or feel unpredictable?
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Yes – vary with stress/environment
Sometimes – some variation
No – steady
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TRIGGERS, TESTS & TREATMENTS
8. Do emotional stressors or certain situations make your symptoms worse?
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Yes
Maybe
No
9. Have your imaging or test results (like MRI, X-rays, or bloodwork) matched the severity of your symptoms?
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No – my tests came back normal or doctors couldn’t find anything wrong
Kind of – there were findings (e.g. arthritis, disc bulge), but they didn’t fully explain the pain I’m in
Yes – my results clearly showed something and I believe it explains my symptoms
What were you told your test results or diagnosis showed? (Optional)
10. Have you been given a specific diagnosis or explanation for your pain or symptoms?
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Yes – vague explanation like “stress”
No – no clear diagnosis
Yes – structural diagnosis (disc, arthritis, etc.)
Self-diagnosed
If yes, what diagnosis were you given (or what do you believe it is)? (Optional)
11. Have you tried multiple treatments without lasting results?
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Yes – I’ve tried many (physio, injections, massage, meds, etc.) and the pain always returns
Somewhat – I’ve had temporary relief, but nothing long-term
No – I haven’t explored much yet
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PERSONALITY, EMOTIONS & LIFE PRESSURE
12. Which of these describe you most of the time? (Check all that apply)
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I hold myself to very high standards or feel like I’m never doing enough
I avoid conflict and keep my true feelings to myself
I put others’ needs first and feel guilty for prioritizing myself
I push through pain or burnout to meet responsibilities
I struggle to rest unless I feel I’ve earned it
None of these
Q12 Score
13. When it comes to emotions like anger, frustration, or resentment, how do you usually respond?
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I hold it in—I don’t want to seem dramatic or cause tension
I distract myself and keep going
I journal or vent privately but rarely say how I feel
I express it calmly and speak my truth
I react quickly and often yell—I get overwhelmed easily
I’m often numb or unsure what I feel
Q13 Selection Count
Q13 Score
14. How would you describe your current emotional stress levels in these areas? (Select those that feel heavy or draining right now
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Relationships (partner, children, family, friends)
Career or work-life balance
Finances or financial security
Health, chronic symptoms, or body image
Identity, purpose, or self-worth
I feel mostly at peace in these areas
Q14 Score
Q14 Stressor
15. As a child, did you feel emotionally safe to express how you truly felt?
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No – I had to hide emotions, be strong, or earn love by performing
Kind of – I was loved, but I often felt unseen or unsupported
Yes – I felt safe, validated, and emotionally free
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MIND-BODY CONNECTION
16. Do you ever feel like your body might be holding onto stress, emotion, or past experiences?
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Yes – I’ve felt this deeply
Maybe – I’ve started to notice a connection
No – I believe this is purely physical
17. Have you ever noticed symptom relief after releasing emotions or moving your body?(e.g. crying, journaling, breathwork, dancing, walking, yoga, exercise or other movement)
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Yes – I feel lighter or less tense after letting emotions out or moving my body
Not sure – I’ve tried those things but haven’t paid attention to the effect
No – I haven’t noticed any change from those things
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BELIEFS ABOUT YOUR BODY, DIAGNOSIS & HEALING
18. What do you believe is causing your pain or symptoms?
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Physical damage, wear and tear, or a broken body
A mix of physical issues and emotional stress
Emotional suppression, trauma, or a sensitive nervous system
I have no idea anymore—I just want answers
19. Have you ever been told (or believed) that your condition is permanent or something you'll just have to manage forever?
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Yes – by a doctor or specialist
Yes – I’ve started to believe that myself
No – I believe healing is possible, I just don’t know how
I feel lost and uncertain about what to believe
20. How do you feel about movement or physical activity when it comes to your symptoms?
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I avoid it—I’m afraid it’ll make things worse
I push through, even when it hurts
I’m overly cautious and hyper-aware of movement
I move freely or I’m beginning to challenge those fears
Total Neuroplastic Score
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