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Retrain Back Pain® New Client Form
Email address
When would you like to meet?
What is your primary concern?
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?
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?
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:
If you have back pain, which activities bother you?
Check all that apply
Do you have a secondary area of concern?
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
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
How would you describe the level of stress in your life?
Check all that apply
Do you smoke cigarettes?
Check all that apply
Do you drink alcohol?
Check all that apply
My joints ache
If you are a woman, have you had children?
Do you experience urinary incontinence?
How would you rate your nutrition?
Check all that apply
I have the following food allergies or sensitivities:
Check all that apply
Your answer
Daily sleep amount
Daily hydration amount
I make my own food
I feel bloated and gassy
I eat sweets
How much time daily are you willing to set aside for recovery homework exercises?
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