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Retrain Back Pain® New Client Intake (Google Form)
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Email address
*
Your email
Your Name
Your answer
Your Address
Your answer
Your Phone
Your answer
What is your primary concern?
Lower back pain
Upper back pain
Neck pain
Sacroiliac joint pain
Hip pain
Knee pain
Shoulder pain
Other
Please tell me your story below:
Your answer
What activities are you unable to participate in that you would like to be able to do again?
Your answer
Date of injury (if applicable):
MM
/
DD
/
YYYY
How did this injury occur?
Your answer
Have you had an x-ray or MRI?
No
No but I plan to
Yes, I had an x-ray
Yes, I had an MRI
Other:
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:
Your answer
Have you had surgery for the present condition?
If yes, please summarize:
Your answer
On a scale of 1 to 5, with 5 being the worst, how would you rate your daily pain?
1
2
3
4
5
Clear selection
Please tell me more below
Your answer
What have you tried to alleviate your discomfort?
Your answer
What successfully alleviates your discomfort?
Your answer
Please check all that apply. My pain is worse:
In the morning
During the day
At night
Pain is constant, all the time
Pain comes and goes, don't know why
Pain moves around
Other:
If you have back pain, which activities bother you?
Check all that apply
Lying down
Standing
Sitting
Walking
Bending
Stairs
Moving too much
Not moving enough
Yoga
Jogging
Cycling
Swimming
Weightlifting
Other:
Do you have a secondary area of concern?
Lower back pain
Upper back pain
Sacroiliac pain
Neck pain
Shoulder pain
Hip pain
Knee pain
Ankle pain
Other:
Clear selection
Anything else you'd like to share?
Your answer
Do you wear any braces or orthotics?
Your answer
MEDICAL HISTORY
PERSONAL MEDICAL HISTORY
Please check all that apply
Arthritis
Diabetes
High blood pressure
High cholesterol
Heart attack
Stroke
Eczema or psoriasis
Inflammatory Bowel Disease, Crohn's, Celiac or other colitis
MS
Cancer
Other:
Clear selection
Are you currently taking any prescription pain medication?
Which ones, for what ailment and how much of each?
Your answer
Are you currently taking any over the counter pain medication (ibuprofin, acetaminophen, aspirin)?
Please list which you are taking regularly and how many milligrams.
Your answer
I take the following nutritional supplements
Your answer
How would you describe your energy levels?
Check all that apply
Low energy
Medium energy
High energy
Other:
Clear selection
How would you describe the level of stress in your life?
Check all that apply
Very little stress
Some stress
Too much stress, I'm kind of frazzled
A lot of stress, but I'm hanging on ok
Unsustainable: I'm concerned about my stress levels
Other:
Clear selection
Do you smoke cigarettes?
Check all that apply
Yes
No
Sometimes
Other:
Clear selection
Do you drink alcohol?
Check all that apply
1 serving daily
1-3 servings daily
More than 3 servings daily
1 serving weekly
1-3 servings weekly
More than 3 servings weekly
Other:
Clear selection
My joints ache
yes
no
Other:
Clear selection
Ladies...
Hysterectomy
Masectomy
DNC
Vaginal birth, easy
Fibroid surgery
Vaginal birth, hard
Cesarean birth, easy
Cesarean birth, hard
Other:
Do you experience urinary incontinence?
Yes only when I run or jump
Yes, only when I sneeze, laugh or cough
Yes
No
Other:
Clear selection
How would you rate your nutrition?
Check all that apply
Meh
Improving
Excellent
No idea
I'm not happy with my nutrition
Other:
Clear selection
I have the following food allergies or sensitivities:
Check all that apply
Your answer
Although I consume them , I've long suspected that the following foods/drinks aren't serving me well
Your answer
Daily sleep amount
under 5 hours
6 hours
7 hours
7 hours
9 hours
10 hours
Other:
Clear selection
Daily hydration amount
8 ounces
16 ounces
24 ounces
32 ounces or more
Clear selection
I make my own food
Never
25%
50%
75%
Always
Other:
Clear selection
I feel bloated and gassy
Never
Sometimes
All the time
Other:
Clear selection
I eat sweets
Never
Sometimes
All the time
Other:
Clear selection
How much time daily are you willing to set aside for recovery homework exercises?
I'm not willing to do recovery homework exercises
10 minutes
20 minutes
30-40 minutes
Other:
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
I understand
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.
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