Muscle Balance Scan

This intake form helps us understand your pain, movement limitations, daily habits, injury history, recovery patterns, and goals. By comparing your answers with your Moti Physio scan data, we can better identify the root causes and the appropriate treatment plan.

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Before we begin

Client information

Tell us who you are so your care team can connect this intake to your record.

  1. Section 1 — Goals and Priorities

    01What are your top 1–3 goals right now?

    Examples: reduce pain, feel less tight, move better, improve posture, recover faster, return to sport, prevent injury, improve flexibility, feel stronger, or understand your body better.

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  2. 02What activity, movement, or position do you want to feel better doing?

    Examples: running, lifting, walking, sitting, standing, sleeping, training, working, driving, golf, tennis, pickleball, cycling, yoga, dancing, or daily movement.

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  3. 03What are you avoiding or modifying because of this issue?

    Examples: certain exercises, sports, work tasks, sitting, standing, lifting, walking, stairs, sleeping positions, or daily activities.

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  4. Section 2 — Activity Level and Daily Demands

    04Which best describes your current activity level?
  5. 05What types of activity, sport, exercise, or movement do you currently do?

    Include how often you do them.

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  6. 06What does your typical day look like physically?

    Include sitting, standing, walking, driving, lifting, computer work, repetitive movements, training, or anything your body does often.

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  7. Section 3 — Main Concern

    07What is your main concern today?

    Choose any that apply.

  8. 08Where do you feel the issue most?

    Include the body area and side: left, right, both, center, or moving around.

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  9. 09When did this issue start, and did it begin from a specific injury or gradually?

    Examples: recent, weeks ago, months ago, more than 6 months ago, years ago, specific injury, gradual onset, recurring pattern, or not sure.

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  10. Section 4 — Symptom Pattern

    10How would you describe the feeling, and how intense is it from 0–10?

    Examples: tight, stiff, achy, sharp, sore, weak, unstable, burning, tingling, numb, heavy, restricted, pinching, cramping, or tired.

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  11. 11What makes it worse?

    Examples: sitting, standing, walking, running, lifting, stairs, training, stretching, sleeping, driving, stress, or certain positions.

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  12. 12What makes it feel better?

    Examples: movement, rest, massage, stretching, heat, ice, sleep, changing position, exercise, shoes, orthotics, or recovery therapy.

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  13. Section 5 — Posture, Movement, and Muscle Balance

    13Do you notice any posture, movement, tightness, weakness, or imbalance that may be connected?

    Examples: one shoulder higher, leaning to one side, rounded shoulders, flat feet, arching the low back, locking the knees, walking differently, tight hips, weak glutes, stiff ankles, or favoring one side.

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  14. 14How are your sleep, stress, energy, and recovery right now?

    Examples: good, okay, poor, waking up sore, waking up tired, high stress, low energy, not recovering from workouts, or feeling run down.

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  15. Section 6 — History and Safety

    15Have you had any previous injuries, surgeries, imaging, diagnosis, or treatments related to this issue?

    Include what happened, what you tried, what helped, and what made things worse.

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  16. 16Do you have any symptoms or safety concerns we should know about before treatment?

    Include numbness, tingling, weakness, balance changes, coordination changes, symptoms traveling down the leg or into the arm, major swelling, redness or heat around a joint, fever, unexplained weight loss, severe night pain, chest pain, shortness of breath, bowel or bladder changes, saddle numbness, rapid strength loss, new neurological symptoms, recent trauma, or inability to bear weight.

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