Consultation Intake Form
Thank you for your interest in working with Brian!

Brian Carroll's assistant, Bristol, will be reaching out via email, with Brian's recommendation for you based on the information you provide in this form. Please fill out all questions in there entirely to ensure Brian is able to curate the best recommendation for you.

For any additional information regarding Brian, his services, books, client testimonials, and answers to frequently asked questions, please visit powerrackstregnth.com.  

Thank you! 
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Name *
Email *
Phone Number *
Address 
(Please give your best mailing address) 
 *
Age *
Weight *
Height *
Occupation  *
Please share how you heard of me and what made you book with me. *
Required
Have you been to a primary care Doctor to check red flags? I.e., Cauda Equina syndrome, genital pain, bladder control loss, etc. History of trauma, physical or psychological, fibromyalgia, autoimmune disorders, etc? If yes, please explain.  *
Are you currently in litigation in any capacity for your back injury you are consulting with me on?  *
Have you been physically assessed for back pain? How long was the assessment? Who did you go to? *
Pain 
Please check all that apply  *
Required
What are your symptoms, and how bad are they? On a scale of 1-10, 1 is very little, more annoying, with 10 being unbearably bad and painful; I need to go to the ER.  *
Very little Pain
Unbearable Pain
Describe the pain and does it ramp up? What are the sensations in the back and down the arms and or legs if applicable - Would you describe as burning, numb, spasming, twitching, Cramping and locking down, tingling, stinging, aching, etc.
 *
Back Related Surgeries
Please check all that apply 
 *
Required
If you check one or more of the back related surgeries, please list the specific surgery below. 
Please describe how you hurt yourself -  Was the initial cause traumatic? I.e., a Car accident, a fall, etc. Or was it a slow build-up over time? How long ago? *
Where are your symptoms? Upper back? Mid-back? Low back? In the center of your back? Do they change, move, or migrate from your back down your leg, or is it just in your back? *
How long have you been in pain? How long have you been dealing with this?  *
Do you experience catches of pain when you roll over (in bed) or sudden jolts of pain while walking on uneven ground, stepping off a curb, transitioning, or moving in specific ways? *
Are your back pain/symptoms worse in the am or the pm (morning or evening) - is there a trend? *
What are the causes of the pain you discovered in the assessment in chapter 6 of Back Mechanic? Please list. *
What have you failed in an attempt to fix your back? Chiro, PT? - what have you tried? *
What has worked? What has not? *
What is your injury history besides your back - i.e., knee, hip, ankle - surgery? Replacement? Etc *
What is your job? What are the demands? Are they stressful, manual labor, intense and prolonged, etc.? *
Do you have time when you feel pretty good or close to pain–free? *
Does sitting cause pain? *
Does walking cause pain? *
What can you do pain-free, i.e., "I can sit all day. Walking feels great.” Please list *
What can't you do pain-free? "sitting kills my back after just a couple of minutes." Please list. *
Do you ever have good days? When was your last good day of low to no symptoms? *
What is your current recovery and training program? Please list. *
Have you had an MRI? *
If you've had an MRI, when?  *
Extras
Please check all that apply
Hobbies/Interests?

(e.g., Photography, Painting, Music, Woodworking, etc.)

 *
Do you have a history of sports, such as weightlifting, powerlifting, football, dance, ballet, gymnastics, or martial arts, or other related physical activities?  *
Goals
Please check all that apply
 *
Required
How can I best help you? Any additional information you'd like to provide? *
Have you read Back Mechanic by Professor McGill? *
Have you read Gift Of Injury by Brian Carroll & Professor McGill? *
It is highly recommended to have read Back Mechanic and Gift Of Injury before working with Brian. If you have not yet secured your copy of either book, you can do so through the links below!

Please check that all the information you have provided is correct and questions answered fully. The information you have provided will be used to curate Brian's recommendation for you.

REMINDER:  Brian Carroll is not a medical doctor and is not administering you medical advice. Brian advocates for help with education, movement, and training approaches and techniques to beat pain and injury. He has lived it and understands what it’s like to be hurt.

By checking the boxes below you are confirming that all the information you have provided is true and correct and understand that Brian is not a medical doctor and will strictly act only as your advisor. 

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