Alexander Technique Student Information
First Name
Last Name
Mobile Phone
Home Phone
Email
Address
Address Line 2
City
Zip
Birth Date
Employment Status
Employed full-time
part-time
self-employed
unemployed
retired
care-giver
Occupation
What days and times work best for you to schedule lessons?
Have you had Alexander lessons before? If so, which whom/where?
How did you hear about the Alexander Technique?
How did you hear about Molly and the Integrated Motion Studio?
What interests, activities, and exercises are you regularly involved in?
Are any of your activities limited by pain, tension, or decreased mobility? Which ones? How?
If you experience pain, tension, or decreased mobility in your head or neck, please describe it:
If you experience pain, tension, or decreased mobility in your back, spine, chest, or pelvis, please describe it:
If you experience pain, tension, or decreased mobility in your shoulders, arms, or hands, please describe it:
If you experience pain, tension, or decreased mobility in your hips, legs, or feet, please describe it:
What other relevant medical history should I know?
What types of traditional or alternative treatments have you tried?
What goals would you like to address with Alexander lessons?
Is there anything else I should know?
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