Spinal Energetics Intake

Name *

First Name

Last Name

Phone *

Country

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1. Where do you feel the most tension or discomfort in your body? *

Select all that apply.

Neck and shoulders—always tight, no matter what I do

Lower back & hips —stiff, sore, or aching constantly

Jaw—clenching, grinding, or tension I don’t notice until it hurts

Chest—feels heavy, like it’s hard to breathe fully

Stomach—bloating, nausea, or digestion issues when I’m stressed

Hands or feet—tingly, restless, or always cold

4. What have you tried to help you with this? *

Select all that apply

Massages, stretching, or chiropractic work

Meditation, therapy, or journaling

Changing my diet, supplements, or hydration

Pushing through and hoping it gets better on its own

Group fitness classes, pilates, yoga, or personal training