All Clients Self-Assessment Body Map
Date of Birth:
Symptom 1 Location
Head-Right Side
Head-Left Side
Head-Front
Head-Back
Neck-Right Side
Neck-Left Side
Neck-Front
Neck-Back
Shoulders-Right Side
Shoulders-Left Side
Chest
Upper Back
Upper Arm-Right Side
Upper Arm-Left Side
Lower Arm-Right Side
Lower Arm-Left Side
Hand-Right
Hand-Left
Mid Back
Mid Front
Lower Back
Abdomen
Right Side
Left Side
Pelvic Area
Buttocks
Upper Thigh-Right Side
Upper Thigh-Left Side
Back Upper Thigh-Right Side
Back Upper Thigh-Left Side
Knee-Right
Knee-Left
Back of Knee-Right
Back of Knee-Left
Shin-Right
Shin-Left
Calf-Right
Calf-Left
Foot-Right
Foot-Left
Symptom 1 Intensity
Symptom 1 Duration
Symptom 1 Frequency
Symptom 1 Onset
Sympton 1:
Adhesion
Rotation
Pain
Tender points
Hypertonicity
Spasm
Inflammation
Trigger point
Elevation
Sympton 1 notes:
Symptom 2 Location
Head-Right Side
Head-Left Side
Head-Front
Head-Back
Neck-Right Side
Neck-Left Side
Neck-Front
Neck-Back
Shoulders-Right Side
Shoulders-Left Side
Chest
Upper Back
Upper Arm-Right Side
Upper Arm-Left Side
Lower Arm-Right Side
Lower Arm-Left Side
Hand-Right
Hand-Left
Mid Back
Mid Front
Lower Back
Abdomen
Right Side
Left Side
Pelvic Area
Buttocks
Upper Thigh-Right Side
Upper Thigh-Left Side
Back Upper Thigh-Right Side
Back Upper Thigh-Left Side
Knee-Right
Knee-Left
Back of Knee-Right
Back of Knee-Left
Shin-Right
Shin-Left
Calf-Right
Calf-Left
Foot-Right
Foot-Left
Symptom 2 Intensity
Symptom 2 Duration
Symptom 2 Frequency
Symptom 2 Onset
Symptom 2:
Adhesion
Rotation
Pain
Tender points
Hypertonicity
Spasm
Inflammation
Trigger point
Elevation
Symptom 2 notes
Symptom 3 Location
Head-Right Side
Head-Left Side
Head-Front
Head-Back
Neck-Right Side
Neck-Left Side
Neck-Front
Neck-Back
Shoulders-Right Side
Shoulders-Left Side
Chest
Upper Back
Upper Arm-Right Side
Upper Arm-Left Side
Lower Arm-Right Side
Lower Arm-Left Side
Hand-Right
Hand-Left
Mid Back
Mid Front
Lower Back
Abdomen
Right Side
Left Side
Pelvic Area
Buttocks
Upper Thigh-Right Side
Upper Thigh-Left Side
Back Upper Thigh-Right Side
Back Upper Thigh-Left Side
Knee-Right
Knee-Left
Back of Knee-Right
Back of Knee-Left
Shin-Right
Shin-Left
Calf-Right
Calf-Left
Foot-Right
Foot-Left
Symptom 3 Intensity
Symptom 3 Duration
Symptom 3 Frequency
Symptom 3 Onset
Symptom 3:
Adhesion
Rotation
Pain
Tender points
Hypertonicity
Spasm
Inflammation
Trigger point
Elevation
Symptom 3 notes
Rate how you are feeling today (0= No pain, 10= worst pain imaginable)
Rate how you are feeling today (0= Able to do everything, 10= Not able to do anything)
Is there anything else I should know about how you are feeling today or about your progress or care to date?