Changes can be made until the questionnaire is submitted.

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* 1. Name: (First and Last)

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* 2. Date:

Date

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* 3. Date of Birth:

Date

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* 4. Current age:

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* 5. Preferred phone number:

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* 6. Preferred email:

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* 7. Address

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* 8. Continued Address

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* 9. Right or left handed:

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* 10. Marital Status/Spouse's name:

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* 11. Children/Names and ages:

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* 12. Parents and Sibling health:

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* 13. Are there any of these medical issues within your immediate family (Parents, siblings, biological aunts or uncles)? If yes, whom?

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* 14. Current or most recent job:

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* 15. Rate your ability to play by ear (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 16. Primary instrument:

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* 17. At what age did you begin playing your instrument?

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* 18. Do you play any secondary instruments? If yes, what and do you continue to play them?

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* 19. Describe, in as much detail as you can, your musical training. (Include all studio teachers and methodology).

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* 20. Have you experimented with equipment changes?

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* 21. When did you begin to experience difficulties in your playing? At what age?

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* 22. How long have you been experiencing performance difficulties?

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* 23. Do you experience any pain while playing your instrument? Describe 

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* 24. Was there any life altering event during the time of the onset of performance issues? 

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* 25. Describe what you felt was the onset and progression of your performance difficulties. (Please be VERY detailed)

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* 26. Describe everything you have done to remedy the performance difficulty. Again, please be VERY detailed.

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* 27. Have you seen a doctor about the difficulty that you are experiencing?

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* 28. Have you been diagnosed with Musician's Dystonia? If so, when and by whom?

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* 29. Are there other medical issues that may be pertinent that you are willing to share? (All information is strictly confidential).

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* 30. Describe yourself, including temperament, work ethic, long term goals, etc.

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* 31. Would you describe yourself as a visual, auditory, or kinesthetic learner? Give percentages. 

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* 32. How would you describe your temperament? (Type A/B personality?)

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* 33. Rate your quality of sleep (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 34. How many hours of sleep on average?

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* 35. How much water do you drink daily?

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* 36. Rate your level of stress in every day life. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 37. Rate your level of stress during rehearsals. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 38. Rate your level of stress during performances. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 39. Rate your ability to focus your attention. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 40. Rate your ability to work independently. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 41. Rate you level of perfectionistic tendencies in regards to music. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 42. Rate you level of perfectionistic tendencies in regards to other endeavors. (0-10)

0 10
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i We adjusted the number you entered based on the slider’s scale.

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* 43. Do you participate in activities that require a high level of focus of attention? 

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* 44. Are you athletic? If so, what sports have you participated in?

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