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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):
MM
/
DD
/
YYYY
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?
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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?
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Anything else you'd like to share?
Do you wear any braces or orthotics?
MEDICAL HISTORY
PERSONAL MEDICAL HISTORY
Please check all that apply
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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
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How would you describe the level of stress in your life?
Check all that apply
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Do you smoke cigarettes?
Check all that apply
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Do you drink alcohol?
Check all that apply
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My joints ache
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Ladies...
Do you experience urinary incontinence?
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How would you rate your nutrition?
Check all that apply
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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
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Daily hydration amount
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I make my own food
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I feel bloated and gassy
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I eat sweets
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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.
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