Getting to Know You
Please take your time filling this out. This helps me understand your history, symptoms, and goals so we can make the most of our time together.
Name
First Name
Last Name
Today's Date
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How did you hear about Train Outta Pain?
Referral
Youtube
Social media
Friend/family member
Google Search
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What brings you in today?
Describe any current pain, discomfort, or limitations
Have you had any major injuries, accidents, or traumas? Please list them.
Have you ever received general anesthesia for any procedure?
Yes
No
Have you had any surgeries? Please list them all including cosmetic surgery, biopsies, or mole removals.
List any place beside your ears that you have had a piercing.
List anywhere on your body that you have a scar regardless of the age of it.
What treatments or therapies have you tried in the past?
What was helpful and what was not?
What are your goals or what would progress look like to you?
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Have you had a blow to the head from a strike, fall, blunt object, or car accident?
Yes
No
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Brain Region Symptom Checklist
INSTRUCTIONS: Rate each symptom using the scale below. Complete every item. This information helps us tailor treatment based on neurofunctional patterns. 0 = I never have symptoms (0% of the time) 1 = I rarely have symptoms (25%) 2 = I often have symptoms (50%) 3 = I frequently have symptoms (75%) 4 = I always have symptoms (100%)
Frontal Lobe (Prefrontal, Dorsolateral, Orbitofrontal)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Difficulty with restraint and controlling impulses
Emotional instability (lability)
Difficulty planning and organizing
Difficulty making decisions
Lack of motivation, enthusiasm, interest, and drive
Difficulty removing a melody or sound from mind (perseveration)
Constantly repeating events or thoughts
Difficulty initiating and finishing tasks
Episodes of depression
Mental fatigue
Decrease in attention span
Difficulty concentrating for extended periods
Difficulty with creativity, imagination, intuition
Difficulty appreciating art and music
Difficulty with analytical thought
Difficulty with math and time awareness
Difficulty sequencing ideas, actions, or words
Frontal Lobe (Precentral, Supplementary Motor)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Difficulty initiating arm or leg movements
Arm or leg heaviness (especially when tired)
Increased muscle tightness (arm or leg)
Reduced muscle endurance
Strength difference between left and right sides
Tightness difference between left and right sides
Frontal Lobe (Broca’s Motor Speech Area)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Difficulty producing words (especially when fatigued)
Speaking feels difficult
Speech fluency or pronunciation changes
Parietal Lobe (Somatosensory and Superior Lobule)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Difficulty perceiving limb position
Spatial disorientation when moving or leaning
Frequently bumping limbs into walls or furniture
Recurring injuries in same body part
Hypersensitivity to touch or pain
Parietal Lobe (Inferior Lobule)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Right/left confusion
Difficulty with math calculations
Difficulty finding words
Difficulty with writing
Difficulty recognizing symbols or shapes
Difficulty with simple drawings
Difficulty interpreting maps
Temporal Lobe (Auditory Cortex & Association)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Reduced hearing function
Difficulty interpreting speech in background noise
Difficulty understanding imperfect speech
Need to look at someone’s mouth to understand speech
Difficulty localizing sound
Dislike of rhythmic repetitive music
Dislike of unpredictable multi-instrument music
Ear preference on phone (right, left, none)
Difficulty understanding spoken words
Monotone speech tendency
Temporal Lobe (Medial & Hippocampus)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Inefficient memory
Memory loss affecting daily activities
Disorientation with dates, time, or place
Difficulty remembering events
Misplacing items and difficulty retracing steps
Difficulty remembering addresses
Visual memory challenges
Forgetting where you put phone, keys, wallet, etc.
Difficulty remembering faces
Difficulty matching names to faces
Difficulty remembering words
Difficulty remembering numbers
Difficulty staying on time
Occipital Lobe
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Difficulty distinguishing similar colors
Visual dullness or muted color perception
Poor eye-hand coordination when reaching
Floaters or halos in visual field
Cerebellum (Spinocerebellum)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Balance difficulties (worse on one side)
Need to hold railing or watch each step going downstairs
Unsteady in darkness
Tendency to sway to one side when walking
Cerebellum (Cerebrocerebellum)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Recent hand clumsiness
Frequent tripping or foot clumsiness
Hand shakes at end range when reaching
Cerebellum (Vestibulocerebellum)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Episodes of dizziness or disorientation
Back muscles tire easily when standing or walking
Chronic back or neck tightness
Nausea, motion sickness
Feeling of shifting environment or disorientation
Anxiety in crowded places
Basal Ganglia (Direct Pathway)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Movement slowness
Muscle stiffness that eases with movement
Hand cramping when writing
Stooped posture while walking
Softer voice
Changes in facial expression (appearing upset)
Basal Ganglia (Indirect Pathway)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Uncontrollable muscle movements
Need to clear throat or twitch muscles
OCD tendencies
Restless or nervous mind
Autonomic (Reduced Parasympathetic Activity)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Dry mouth or eyes
Difficulty swallowing large pills or food
Slow bowel movements or constipation
Chronic digestive complaints
Occasional bowel/bladder incontinence
Autonomic (Increased Sympathetic Activity)
Rows
0 – Never
1 – Rarely
2 – Often
3 – Frequently
4 – Always
Tendency for anxiety
Easily startled
Difficulty relaxing
Light sensitivity (especially to flashing lights)
Episodes of racing heart
Difficulty sleeping
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Do you or have you experienced any of the following?
Pain that moves or shifts with no clear cause
Movement that feels restricted or unstable
Chronic tension that doesn't improve with stretching or exercise
Shallow, stuck, or strained breathing
Jaw tension, clenching, popping or clicking
Visual or balance issues
Fear of movement or making things worse
Fatigue that feels out of proportion to activity
A feeling of disconnection from parts of your body or instability when moving
Shiny hairless legs
Have been choked/choked on food or an object
Trouble swallowing
Frequent throat clearing
Cold fingers or toes
Varicose veins
Blood pressure issues
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Do you wake at night to urinate?
Yes
No
Do you experience leaking when coughing, sneezing, or laughing?
Yes
No
During natural childbirth, did you or were you
Tear
Have to be cut (episiotomy)
Neither
Do you experience any of the following?
Numbness or tingling in genitalia
(Women) Painful intercourse
(Men) Uneven testicles
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Have you had any eye injuries, surgeries, or vision therapy?
Do you feel like one eye works harder than the other?
Do you notice any dizziness, blur, or strain during reading, screens, or tracking?
Is it difficult to look in a specific direction?
If yes, which direction?
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If you experience back pain, where is it located?
Have you sprained any joints (e.g., ankles, wrists)?
Please list any bones you may have broken or fractured
Do you have areas that feel unstable or prone to giving out?
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Do you breathe mostly through your nose or mouth?
Nose
Mouth
Have you ever had the wind knocked out of you?
Yes
No
List any of the following if you experience them regularly
Heartburn
Acid reflux
Indigestion
Food coming up after eating
Do you react strongly to sounds, lights, smells, or tags/seams?
Yes
No
Do you clench or grind your teeth, especially at night?
Yes
No
Describe anything unusual about your breathing, jaw, or tongue position
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What do you most want to change about how your body feels or functions?
Is there anything else you'd like me to know?
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