Get Informed & Get Inspired: Dystonia in Musicians Enrollment Form All information and videos provided will be kept confidential. We will not disclose your personal information to a third party without your consent. Name* Age* Gender* MaleFemale Profession* City/Country* Phone Number* Email Address* Symptoms and Medical History Instrument* The Main Area of Concern: (multiple-choice)* Hand/ ArmFoot/ LegEmbouchureVocal CordOthers Please briefly describe your symptoms, how long have you had this condition, and which side of the body (left and right) is affected.* Have you ever been to the hospital for a doctor's diagnosis?* YesNo What have you done for this condition? (multiple-choice)* BotoxMedicationPhysical TherapyAcupunctureSomatic TechniquesOthers Do you have any chronic diseases? Comment Applicable Time for Sessions (multiple-choice)* WeekdaysWeekdays eveningWeekend Please upload videos which you demonstrate your symptoms.* Thank you for filling out the form. Dr. Monica Chen will review your documents and let you know if you are accepted for the service.