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Name *

First Name

Last Name

Phone *

(###)

###

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Preferred Contact Method *

Email

Phone

What is your biggest problem area? Our movement sessions will be full body, but this is important! *

Please try to select no more than 3 problem areas.

Neck

Shoulders

Wrists

Ribs

Hips

Knees

Ankles

Feet

Other

What are your current diagnoses? *

Ehlers Danlos Syndrome and/or a Hypermobility Spectrum Disorder

A form of Dyautonomia/Nervous System Dysfunction

Gastroparesis

Mast Cell Activation Syndrome

Endometriosis

Anxiety/Stress

Depression

Craniocervical Instability

Chiari Malformation

Vascular Compression Syndromes

Tethered Chord

Other

If you are interested in finding a Physical Therapist familiar with EDS/have found one, what is holding you back from working with them?

Cost per visit

Distance to facility

Health Insurance

If you answered "a few times a week," what is your choice of movement?

Walking

Pilates based

Strength training

Swimming

Cycling

Other