Request edit access
Retrain Back Pain® New Client Intake (Google Form)
Email address *
Your Name
Your Address
Your Phone
What is your primary concern?
Please tell me your story below:
What activities are you unable to participate in that you would like to be able to do again?
Date of injury (if applicable):
How did this injury occur?
Have you had an x-ray or MRI?
Are you currently under the care of an orthopedic doctor, physical therapist or other specialist?
Please provide date of visit, practitioner names and the diagnosis received:
Have you had surgery for the present condition?
If yes, please summarize:
On a scale of 1 to 5, with 5 being the worst, how would you rate your daily pain?
Clear selection
Please tell me more below
What have you tried to alleviate your discomfort?
What successfully alleviates your discomfort?
Please check all that apply. My pain is worse:
If you have back pain, which activities bother you?
Check all that apply
Do you have a secondary area of concern?
Clear selection
Anything else you'd like to share?
Do you wear any braces or orthotics?
Please check all that apply
Clear selection
Are you currently taking any prescription pain medication?
Which ones, for what ailment and how much of each?
Are you currently taking any over the counter pain medication (ibuprofin, acetaminophen, aspirin)?
Please list which you are taking regularly and how many milligrams.
I take the following nutritional supplements
How would you describe your energy levels?
Check all that apply
Clear selection
How would you describe the level of stress in your life?
Check all that apply
Clear selection
Do you smoke cigarettes?
Check all that apply
Clear selection
Do you drink alcohol?
Check all that apply
Clear selection
My joints ache
Clear selection
Do you experience urinary incontinence?
Clear selection
How would you rate your nutrition?
Check all that apply
Clear selection
I have the following food allergies or sensitivities:
Check all that apply
Although I consume them , I've long suspected that the following foods/drinks aren't serving me well
Daily sleep amount
Clear selection
Daily hydration amount
Clear selection
I make my own food
Clear selection
I feel bloated and gassy
Clear selection
I eat sweets
Clear selection
How much time daily are you willing to set aside for recovery homework exercises?
Please confirm that you understand I have a 24 hour cancellation policy. This means that you will be charged full rate of your appointment for any no-shows and for cancellations received within that 24 hour period
Thank you for taking the time to complete this form!
Dinneen Viggiano
A copy of your responses will be emailed to the address you provided.
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy