I consent to being contacted by Toronto Body Mechanic for communications and special offers.

Name *

First Name

Last Name

Phone *

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Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Reason for consultation

I feel well and have no symptoms. I am interested in wellness strategies.

I have an existing issue I wish to resolve, and once it is resolved I wish to improve my general health and continue treatment and prevention.

I have a specific problem and help with this issue only.

The condition is:

Constant

Comes and goes

Getting worse

The condition interferes with:

Work

Sleep

Daily routine

Sports

Have you consulted with:

Physician

Chiropractor

Physiotherapist

RMT

Do you Smoke?

Yes

No

Do you sleep on your:

Back

Side

Stomach

No idea – I'm asleep!

So you sleep well?

Yes

No

Would you like a silent massage?

(No talking, full relaxation.)

Yes

No

Muscle pain and tension

Please check any that apply to you

Back (Right)

Back (Left)

Back (Upper)

Back (Mid)

Back (Lower)

Neck (Front)

Neck (Back)

Neck (Right)

Neck (Left)

Shoulder (Front)

Shoulder (Back)

Shoulder (Right)

Shoulder (Left)

Arm (Front)

Arm (Back)

Arm (Right)

Arm (Left)

Leg (Front)

Leg (Back)

Leg (Right)

Leg (Left)