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We would like to give you some simple exercises to get started, to do that we need to understand you and your back pain in a bit more detail. The following questions will give us a much better picture of how your back is bothering you and give us a helpful starting point on your journey to recovery

    Where is the pain? *

    Pain Level *

    none23456789unbearable

    How long have you had this pain? *

    Less than 6 weeks6 - 12 weeksLonger than 12 weeks

    Was it a sudden or gradual onset? *

    SuddenGradual

    During what activity? *

    WorkFitnessOther

    Is the pain getting worse? *

    Yes, getting worseGoes up and downNo, staying the sameNo, easing

    How long does the pain last? *

    SecondsMinutesHoursConstant

    How would you describe your pain? *

    DullSharpShootingStabbingHeatCold

    What activity were you doing when this pain occured? *

    WorkingExercisingSittingOther

    What are the things that make it feel worse: *

    Bending forwardLeaning backLeaning left or rightSitting downIt hurts when I press the area

    What are the things that ease the pain? *

    Heat or cold packsRestingMovementMassageAnti-inflammatory drugs (NSAID)other

    How would you describe what you do for work: *

    Desk jobPhysical workMixed work

    Are you currently employed? *

    Yes, currently employedNo, currently unemployedI am self-employedI am a student

    Please rate your stress level: *

    I am calm, relaxed, and happyI am feeling okayI am a little anxiousI am worried and stressedI am severely depressed

    During a week, how often do you do yoga or pilates or stretching? *

    NeverOnce a week2-3 times a weekMore than 3 times a week

    During a week, how often do you run, swim or go to the gym? *

    NeverOnce a week2-3 times a weekMore than 3 times a week

    During a week, how often do you do play sports like football, rugby or tennis? *

    NeverOnce a week2-3 times a weekMore than 3 times a week

    Do you have any altered sensations from the waist down? *

    YesNo

    Where? *

    Have you lost any sensation around your groin/genital area? *

    YesNo

    Have you had any unexpected trips or falls or stumbling? *

    YesNo

    Have you had any problems going to the toilet? *

    YesNo

    Any unexplained weight loss?*

    YesNo

    Over what period *

    Weeks

    How much weight? *

    Kilograms

    Have you seen your GP about this? *

    YesNo

    Do you have any history of the following types of medical conditions? *

    YesNo

    Thyroid diseaseHeart diseaseRheumatological conditionEpilepsyDiabetesAsthmaCancerOsteoperosis/peniaOsteoarthritis
    Please list any medications you currently take: *

    Over the counter pain medicationsMultivitamins or other supplementsother

    Do you have any history of surgery (in spine, hip or knee)? *

    YesNo

    What area? *

    SpineHipKnee

    What is your gender? *

    FemaleMale

    Have you had a recent pregnancy? *

    YesNo

    Do you have a history of lower back/knee/hip pain? *

    YesNo

    How frequently do you get lower back pain? *

    Less than once a week2-3 times a weekDailyA few times every day

    How would you rate the intensity of this pain out of ten *

    1 10

    Which of these have you already tried? *

    PhysiotherapyChiropractorPain medicationsSurgeryCBTChange in work/exercise regimeI haven't tried anything yet

    Please tell us your first name *

    Please tell us your surname *

    Please give us your email address *

    Please tell us your phone number

    Fields marked with an * are mandatory