Questionnaire Changes can be made until the questionnaire is submitted. Question Title * 1. Name: (First and Last) Question Title * 2. Date: Date / Time Date Question Title * 3. Date of Birth: Date Date Question Title * 4. Current age: Question Title * 5. Preferred phone number: Question Title * 6. Preferred email: Question Title * 7. Address Question Title * 8. Continued Address City/Town State/Province ZIP/Postal Code Country Question Title * 9. Right or left handed: Right Handed Left Handed Question Title * 10. Marital Status/Spouse's name: Question Title * 11. Children/Names and ages: Question Title * 12. Parents and Sibling health: Question Title * 13. Are there any of these medical issues within your immediate family (Parents, siblings, biological aunts or uncles)? If yes, whom? Movement Disorders? Dystonia, tremors, Parkinsons? OCD (Obsessive Compulsive Disorder)? Bipolar Disorder? Depression? ADD, ADHD? MD (Muscular Dystrophy)? MS (Multiple Sclerosis)? TMJD? Other: Question Title * 14. Current or most recent job: Question Title * 15. Rate your ability to play by ear (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 16. Primary instrument: Question Title * 17. At what age did you begin playing your instrument? Question Title * 18. Do you play any secondary instruments? If yes, what and do you continue to play them? Question Title * 19. Describe, in as much detail as you can, your musical training. (Include all studio teachers and methodology). Question Title * 20. Have you experimented with equipment changes? Question Title * 21. When did you begin to experience difficulties in your playing? At what age? Question Title * 22. How long have you been experiencing performance difficulties? Question Title * 23. Do you experience any pain while playing your instrument? Describe Question Title * 24. Was there any life altering event during the time of the onset of performance issues? Question Title * 25. Describe what you felt was the onset and progression of your performance difficulties. (Please be VERY detailed) Question Title * 26. Describe everything you have done to remedy the performance difficulty. Again, please be VERY detailed. Question Title * 27. Have you seen a doctor about the difficulty that you are experiencing? Question Title * 28. Have you been diagnosed with Musician's Dystonia? If so, when and by whom? Question Title * 29. Are there other medical issues that may be pertinent that you are willing to share? (All information is strictly confidential). Question Title * 30. Describe yourself, including temperament, work ethic, long term goals, etc. Question Title * 31. Would you describe yourself as a visual, auditory, or kinesthetic learner? Give percentages. Visual Auditory Kinesthetic Question Title * 32. How would you describe your temperament? (Type A/B personality?) Question Title * 33. Rate your quality of sleep (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 34. How many hours of sleep on average? Question Title * 35. How much water do you drink daily? Question Title * 36. Rate your level of stress in every day life. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 37. Rate your level of stress during rehearsals. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 38. Rate your level of stress during performances. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 39. Rate your ability to focus your attention. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 40. Rate your ability to work independently. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 41. Rate you level of perfectionistic tendencies in regards to music. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 42. Rate you level of perfectionistic tendencies in regards to other endeavors. (0-10) 0 10 Clear i We adjusted the number you entered based on the slider’s scale. Question Title * 43. Do you participate in activities that require a high level of focus of attention? Question Title * 44. Are you athletic? If so, what sports have you participated in? Next