Part I of Assessment Form Page

How long have you had back pain?

0 to 12 months

1 to 5 Years

5+ Years

20+ Years

Have you had invasive back surgery in the last 6 weeks, or spinal fusion surgery in the last 3 months?

YES

NO

Here are the most common conditions related to Low Back Pain (LBP).

Spinal Stenosis

Herniated or Bulging Disc(s)

Degenerative Disc Disease

Sciatica or other referred pain

Scoliosis

SI joint pain

recent back surgery (post-op)

slipped vertebrae (Spondylolisthesis)

poor posture (lordosis, pelvic tilt, etc)

general or non-specific low back pain

How would you describe your pain?

dull, achy soreness or tenderness

intense or sharp, stabbing pain

unrelenting tightness, stiffness or gripping/spasm

referred leg symptoms (shooting, numbness, tingling, burning/cold or radiating pain)

When your back flares up, how does it affect your life?

Can't sit for long periods

Can't walk or stand up straight

Guarded movement/fear of further injury

Loss of work/income

Negative mood/impact on relationships

Loss of leg or foot function

Depression/anxiety about future

Immobility/bed-bound

Research shows life satisfaction goals are a critical factor in escaping the pain cycle. What motivates you to improve the health of your back?

Do more physical activities I enjoy

Improve physical health/fitness

Improve happiness/mental health

To enjoy my social life

Improve career/professional life

Feel comfort/peace

Improve relationships/sex life

Improve sleep

Are you able to safely get down on the floor?

Yes

No

Are you able to lie on your belly?

Yes

No

We know everyone's pain triggers are unique.

Sitting

Standing in one place

Laying in bed/waking up

Bending, lifting or twisting

Physical activity/exercise

Stress/anxiety

My back hurts all the time

Other/more

Which treatments have you tried?

Chiropractic

Physical Therapy

Acupuncture

Massage (MFR, Rolfing, etc)

Injections

Medication

Surgery

More/other alternative treatments

CBT has an exceptionally high success rate because it teaches you how to use the spinal support muscles deep inside your core.

Yes

No

If you knew it would get you back to pain-free, would you commit 15 mins/day to a proven system for your back?

Yes

No

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