Specific for Patient

Name

First Last

Email

Can you now (or could you ever) place your hands flat on the floor without bending your knees?*

Yes
No

Can you now (or could you ever) bend your thumb to touch your forearm?*

Yes
No

As a child did you amuse your friends by contorting your body into strange shapes or could you do the splits?*

Yes
No

As a child or teenager did your shoulder or kneecap dislocate on more than one occasion?*

Yes
No

Do you consider yourself double-jointed?*

Yes
No

Have you or do you have dental crowding and high or narrow palate*

Yes
No

Do you get dizziness and/or feel faint after sitting up or standing?*

Yes
No

Do your joints feel like they twist easily or injury easily? Does it feel like certain joints may be slipping in and out of place?*

Yes
No

Do you bruise very easily, or have you noticed widened scars or lots of stretchmarks on different parts of the body? Has it been noted that (or do you think that) your skin is more stretchy than other peoples?*

Yes
No

Do you constantly feel tired (physical or mental) - perhaps not refreshed after sleep?*

Yes
No

Is there a lot of stomach acidity / reflux, nausea, or constipation - perhaps multiple food intolerances?*

Yes
No

Do you regularly notice a fast heart rate or feel dizzy as if you might pass out?*

Yes
No

Have you had any bladder concerns? Perhaps difficulties in passing or controlling urine, or repeated burning / painful urine? Leaking while laughing?*

Yes
No

Have you noticed your symptoms are worse around the time of your menstrual period?*

Yes
No

Do you consider yourself to be anxious or depressed?*

Yes
No

Do you have eye, vascular, or bowel problems?*

Yes
No

Consent*

You agree for me to use this data during your appointment and any future referrals we BOTH agree to

Health & Wellness Services

Hypermobility Questionnaire