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Home » Body Map Questionnaire

Body Map Questionnaire

Body Map

Name

Date

Identify any symptoms for each muscle group. Please be as specific as possible

Arms

Arms

Upper armsTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Lower armsTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

Legs

Legs

Upper legTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Lower legTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

Hand and Feet

Hands and Feet

HandsTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

FeetTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

Face and Neck

Face and Neck

FaceTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

NeckTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

Chest and Abdomen

Chest and Abdomen

ChestTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

SidesTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

AbdomenTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

Back

Back

Upper backTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Middle backTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Lower backTension, HypertonicityPainSpasmInflamationNumbness/tinglingNo issues

Describe issue(s)

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Pataskala, OH 43062

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Forms Required for Service:

Health information
Screening Questionnaire
Problem Areas - Body Map

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Copyright 2026, Massage Kneaded Peacefully

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