Cyclo-ssage Therapy Questionnaire - complete and unlock your discount code

Cyclo-ssage Therapy Questionnaire

Thank you for completing this questionnaire to unlock your 30% discount for your 30 minute Trial Session for Cyclo-ssage Therapy. You'll be helping your body to help itself. I appreciate that these questions may seem quite personal in nature but I can assure you that none of your information will be shared with anyone else and they are designed to ascertain the best program to use and to set some short term goals to gauge the effectiveness. Given that you're completing this questionnaire to unlock the discount I think it's fairly safe to say that you'll be booking your trial appointment with us...by having completed this questionnaire then we don't need to do this at your first appointment. I look forward to meeting you soon!!!
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Email*
example@example.com
What ailments or symptoms do you experience on a regular basis?*

Back Pain - UpperBack Pain - LowerArthritisChronic FatigueDiabetesFibromyalgiaHeadachesMigrainesRaised Blood PressureSciaticaDigestive IssuesSleep Issues/DisordersParkinson'sMultiple SclerosisTension and StiffnessJoint PainMuscle AcheSports InjuriesSluggish Lymphatic SystemFluid RetentionPeriod Pain/PMSI have, or have had in the past, blood clots.Other
Choose the condition or symptom from Question 1 that bothers you the most and type it below.*
Choose a second condition or symptom from Question 1 that bothers you the next most and type it below.*

Consider how bad each condition or symptom has been over the last two weeks (either pain or restriction) and score it below.*

	1 - as good as it could be	2	3	4	5	6	7	8	9	10 - as bad as it could be
1. Symptom/Condition One
2. Symptom/Condition Two

Choose one activity (physical, social, or intellectual) that is important to you, and that your symptoms/condition makes difficult or prevents you from doing. Score how bad it has been in the last two weeks.*

	I've been able to take part	I've taken part but it's not always comfortable	It's difficult to take part, I'm turning up.	I haven't been able to take part at all.
1. Symptom/Condition One
2. Symptom/Condition Two

How long have you had the Symptoms/Conditions.*

	0-4 weeks	4 - 12 weeks	3 months - 1 year	1 - 5 years	More than 5 years
1. Symptom/Condition One
2. Symptom/Condition Two

The following options are activities you might do during a typical day. Does your health now limit you in these activities?*

	Not at all	A little	Somewhat	I can't do it
1. Lifting or carrying groceries.
2. Moving furniture while vaccumming
3. Vaccumming
4. Climbing several flights of stairs
5. Walking
6. Walking several blocks
7. Engaging in physical activity
8. Bending down to pick something up off the floor (can you do this comfortably without thinking about it)
9. Sitting down and getting up off a chair (without pain or having to pull yourself up)
10. Getting up and down off the floor
11. Getting out of bed first thing in the morning (without pain)
12. Yard work/gardening

Are you taking any medication for any of the condition/symptoms in Q1?*
If you answered Yes or Sometimes is cutting down on this medication important to you?*
If you answered No, is avoiding medication important to you?*
Has your GP or other medical practitioner ever advised you against using infrared or vibration therapies or having massage therapy? *
Please let us know how you heard about us.*

GraboneSamaritansKaraHandsGoogle SearchLinked InYoutubeReferralFriend or FamilyWebsiteBlog postOther
If friend, family, referral, or other, please let us know who (we have a referral program and would like to reward the person who told you about us)
At 360 RNR Hutt Valley Ltd we offer a variety of products and services to help people with the health & wellbeing. Please tick any and all you would like more information on.*

Postural Alignment Therapy - realign your body to relieve pain and help it work more efficientlyStyku 3D body Scanner - predict your health risksWorkshops/WebinarsNutrition Shakes, Herbal teas, and SupplementsComplimentary 30 Minute Breakthrough Call - Get clear on the outcomes you want and create a pathway to get you there12 Week Health & Wellbeing ChallengesNone of the above
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