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Neuroplastic Symptom Assessment

This assessment to help me learn more about you and your experience with symptoms. Once submitted I will review it prior to your scheduled call. 

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Question 1 of 19

What is your first and last name? 

Question 2 of 19

What is the best email to reach you? 

Question 3 of 19

What is your gender? 

Question 4 of 19

Please describe the physical symptom that's currently distressing you? 

Question 5 of 19

Did you suffer from an injury or infection? If so, please describe. 

Question 6 of 19

Do you have any test results or MRI findings? 

Question 7 of 19

What do physicians say is the cause of your symptom(s)?

Question 8 of 19

What do you think is the cause of your symptom(s)? 

Question 9 of 19

Did the symptom(s) begin during a stressful time or life event? If so, please explain. 

Question 10 of 19

What makes the symptom(s) better or worse? 

Question 11 of 19

Are the symptoms inconsistent? Do they come and go, change in intensity or duration, change depending on the time of day, or days of the week, ect.?

Question 12 of 19

What have you tried to alleviate the symptoms? (please include all medical, pharmacological, and alternative treatments). 

Question 13 of 19

Do you have a history of anxiety, or have you been diagnosed with an anxiety disorder in the past? 

A

Yes

B

No

Question 14 of 19

Do you have a history of childhood trauma, or other traumatic experiences? 

A

Yes

B

No

C

Not sure

Question 15 of 19

Please check the following statements that reflect your experience of symptoms.  

(Select all that apply)
A

Symptom(s) is from an injury/infection that has lasted after normal healing would have occured.

B

Symptom(s) shifts from one location in the body to others.

C

Symptom(s) is on both sides of the body (i.e. both legs, both wrists).

D

Symptom is from an old injury that healed long ago.

E

Symptom has "spread" from one area of the body to other areas of the body.

F

Symptom varies during the day, or depending on where you are, and what you're doing.

G

Symptom is absent with certain activity but occurs later in the day, or next day.

H

Symptom is triggered by things outside of the body including: lights, sounds, computer screens, food, heat, cold, smells, certain positions, clothing, changes in weather, etc.

I

Symptom is worse with stressful situations or the anticipation of stressful situations (i.e. family gathering, work day or other events).

J

Doctors have not been able to pinpoint a cause or different doctors have given different diagnoses.

Question 16 of 19

Please check if you describe yourself in the following ways:

(Select all that apply)
A

People pleaser/difficulty saying no

B

Overthinker/worrier

C

Perfectionist/high expectations of yourself

D

Conscientious

E

A rule-follower

F

Critical self-talk

Question 17 of 19

Please select the statements that feel true to you. 

(Select all that apply)
A

I'm constantly afraid I will make the symptoms worse, so I avoid movements and activities.

B

I'm afraid my body is broken or damaged.

C

I'm so frustrated because these symptoms keep me from doing the things I love.

D

I'm terrified I'll never get better.

E

There must be something structurally or medically wrong with me, or I wouldn't have these symptoms.

F

I'm so angry this is happening to me.

G

Pain always means I have injured my body.

H

I can't stop thinking about the symptoms. They are constantly on my mind.

Question 18 of 19

What do you know about Neuroplastic symptoms or TMS (Tension Myositis Syndrome)? 

Question 19 of 19

How did you hear about my coaching practice? 

Confirm and Submit