1. Is your posture poor? Do you have rounded shoulders and/or forward head posture? Does your head feel heavy to hold? Yes No
2. Is your head tilted to one side and/or your head rotated to one side when you look in a mirror? This can be really subtle Yes No
3. Is one of your shoulders lower than the other? Pull your shoulders back and down and look carefully for one lower than the other. Again it can be subtle. Yes No
4. Do you have some shoulder and/or neck pain/aches, which don't seem to go away? Yes No
5. Does your jaw click when you use it, open it to eat etc. Further check on this; Put your pinkies (little fingers) into your ear canals and chew normally. Do you feel a bumpy dislocation like feeling? This should be a smooth action in your joints. Yes No
6. Do you have any lower back pain or mid back pain (under the shoulder blades) niggles? Yes No
7. Can you move your head from side to side without pain or restriction? Is there a loss of Range of Motion (ROM)? Yes No
8. Do you have any sandpaper, clicking or crunching sounds when moving your head from side to side in a 'NO' action? (i.e. cervical crepitus) Yes No
9. Is your hearing a problem or do you have other ear symptoms (e.g. tinnitus, watery sounds, blockages, vertigo, Meniere’s Disease, otalgia, recurrent ear infections)? Yes No
10. Do you often get headaches or migraines? Yes No
11. Can you remember any trauma (even minor) to the head, neck or shoulders? Yes No
12. Was your birth difficult? Yes No
13. How's your vision? – Sensitive to light, especially at dusk, floaters? Yes No
14. Do you experience any dizziness, vertigo or movement sensations (i.e. loss of proprioception)? Does the ground seem to move away from you? Yes No
15. Do you experience any tingling and burning sensations especially in fingers and toes? Yes No
16. Do you have confirmed Scoliosis of the spine, from x-rays? Do you have one leg shorter than the other or is your pelvis higher on one side? Yes No
17. Have you had any x-rays, CT scans or MRIs taken of your cervical spine (neck)? Do these reveal loss of cervical lordosis (neck curve), even a small amount Yes No
