Therapeutic Request | Meraki Total Body

Therapeutic Service Questionnaire

Please fill out the following forms to help us personalize your service and begin forming a Pain Management Plan that fits your lifestyle.

Personal Information

First Name

Last Name

Phone

Occupation:

The following questions will give us a general idea of your lifestyle in areas of Self Care. Knowing your current habits and views will help us to best build a pain management plan that works for YOU.

1) We define "Self Care" as set Time and Activities that are intended to better your physical and/or mental wellbeing. Choose an option that BEST describes the amount of time you dedicate to Self Care:

I do NOT dedicate any time for myself. Self care is ocassional and only when NEEDED.

I have 1-2 Self Care activities that I participate in per month.

1-2 days per week are set aside for "Me Time"

I give myself at least an hour of self care 3 or more days a week.

My body is a well oiled machine that is under constant care.

2) Choose an option that BEST describes your: Level of Physical Activity:

Zero- I am immobile and have a condition that does not allow for most physical activity.

Minimal- I am mobile and capable of physical exertion if needed. I have a career that requires me to sit or stand in one place for long periods of time. I prefer sedentary pastimes such as TV, reading or video games.

Moderate- My career requires that I move throughout my day but is not deemed "Physically Demanding". I regularly engage in activities such as gardening, dog walking, golf or hiking. I try to remember to workout at least once a week.

Heavy- I have a physically demanding career. I enjoy highly physical pastimes such as sports, outdoor activities or frequent exercise. I spend less than 5 hours of my average day sitting.

Extreme- More than 80% of my day is devoted to physical activity. The staff at my gym all know me by name. I do not sleep more than 6 hours. No pain no gain EVERYDAY.

3) Choose an option that BEST describes your: Typical Level of Stress:

Very Little- I don't worry... about a thing... because every little thing... is going to be alright.

Some- I may feel stressed only a handfull of times per month. (running late for an appointment, family emergencies, ect). My stress level does not affect me any way physically that I'm aware of.

Average- My job and/or homelife can cause mild-moderate stress 1-2 time per week. I may experience ocassional headaches or insomnia

High- I have a highly stressful career and/or homelife. I find myself constantly planning and moving from one task to the next most days. I have chronic pain 3 or more day per week. I frequently feel emotions such as worry or anger.

Extreme- I have a medical condition that greatly impacts my daily life. I require daily medication in order to function throughout my day. Migraines,Anxiety, Insomnia and Digestive Issues are frequent.

4) Choose the option that BEST describes your feelings toward: Making changes to your Self Care Routine in order to feel your best:

I am too busy/tired to add anything more into my routine.

My pain is not my fault so there is nothing that I should have to change.

I'd be open to making small changes that don't interfere with my typical routine.

I'd be open to more hands-on bodywork but I am not interested in additional excersise.

Pain and discomfort are rare for me. I am happy with my current routine.

I have a strong desire to create a new routine that will keep me feeling my best.