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are pain FREE in 8 weeks
     
 
Back Pain Consultation Form
 
Name :
Sex :
M F
Address :
Apt #. :
City :
State/Prov. :
Zip Code :
Country :
Email :
Phone :    
     

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Credit Card Information
This must match the credit card.
Type of card :
Credit card
number 		:
Card expiration
date 		: Month
    Year   
Your Total : $
     
Age :
Weight :
LBS : Kgm.
Height :


How long have you had back pain?
 
How did you injure your back ?
 
 
Where does it hurt?
Central Right : Left :
 
Is there radiation ?
Yes No Right : Left :
How far is there radiation ?
Waist line : Buttocks : Back of Thigh : Side of Thigh :
 
Knee : Leg : Ankle : Foot :
 
Bottom : Top : Front of Thigh :
 
There is no radiation, but I have pain in my Ankle
Rt : Lt :
 
My Foot
Rt : Lt : Top : Bottom :
 
Is there any tightness in the Thigh/Leg?
Yes : No :
 
Which Thigh?
Rt : Lt :
 
Which leg?
Rt : Lt :
 
Is there any weakness in the thigh/leg?
Yes : No :
 
Which Thigh?
Rt : Lt :
 
Which leg?
Rt : Lt :
 
Any loss of muscle bulk in thigh/leg?
Yes : No :
 
Rt. thigh : Lt. thigh : Ant : Post :
 
Rt. Leg : Lt. leg : Post :
 
What increases your back pain?
Standing : Walking : Sitting : Bending :
 
Lifting : Reaching : Driving : Cleaning :
 
Cooking : Sleeping : Sex : Other :
 
Describe your pain Intensity:
 
 
What relieves your pain?
 
 
Standing up straight, drop your head forward, do you see your toes?  
Yes : No :
 
How long can you walk for?
5-10 mins : 10-15 mins : 15-20 mins : 20-30 mins :
 
more than 30 mins :
 
Have you had an X-ray/MRI/CT Scan?
Yes : No :
 
What were the results?
 
 
What medication are you taking?
 
 
Do you have difficulty sleeping?
Yes : No :
 
Do you use proper bed exchange when getting out of Bed?  
Yes : No :
 
In bed, do you have difficulty turning?
Yes : No :
 
Are you able to do exercises?
Yes : No :
 
Which exercises are difficult for you?
 
 
Do you have regular bowel function?
Yes : No :
 
Which sport activity do you want to return to?
 
 
Are you walking daily?
Yes : No : 15 mins : 30 mins :
 
Are you drinking 4-6 glasses of water daily?
Yes : No :
 
Are you using a BackVitalizer?
Yes : No :
 
How old is your mattress?
Under 5 years : Over 5years :  over 10 years :
 
Is it a firm mattress?
Yes : No :
 
Do you sleep on your stomach?
Yes : No :
 
Are you using a good back belt?
Yes : No :
 
Are you taking liquid nutrition for your health and stress?
Yes : No :
 
Have you broken any leg/thigh bones?
Yes : No :
 
 
 
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