Active Backs Participant Form
In order to help you achieve the greatest benefit from Active Backs, we need to know a little more about you. Please take a few minutes to complete this form.
Name *
Your answer
Date of birth *
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DD
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YYYY
What is your occupation? *
Your answer
Do you currently have any injuries? *
If yes, please provide further details
Your answer
Please provide further details of your back problems
When did you first experience back pain?
Your answer
Describe your back pain
Your answer
What makes your back pain worse?
Your answer
What eases your back pain?
Your answer
How does your back feel when you wake up?
Your answer
Anything else you'd like us to know about your back pain?
Your answer
General Health
Do you suffer with any of the following?
Asthma? *
Heart problems? *
Rheumatoid Arthritis? *
Diabetes? *
Osteoporosis? *
Have you had any recent surgery? *
Are you pregnant or have you recently given birth? *
Have you recently lost weight? *
Do you suffer with any bladder or bowel issues? *
Do you experience pain at night? *
Are you taking any medication? *
Please provide further details if you have answered yes to any of the questions above.
Your answer
Do you take part in any regular exercise?
Your answer
What are you hoping to achieve from coming to Active Backs?
Your answer
Thank you
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