Lower Back Muscle Release Intake Form
Please complete this form to help us understand your needs and ensure a safe, effective lower back muscle release session.
Full Name
*
First Name
Last Name
Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
*
example@example.com
Describe your current lower back symptoms or discomfort.
*
When did your lower back discomfort begin?
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Please rate your current lower back pain.
*
No pain
0
1
2
3
4
5
6
7
8
9
Worst pain
10
0 is No pain, 10 is Worst pain
Have you experienced any of the following related to your lower back?
*
Previous injury
Surgery
Chronic pain
Muscle spasms
Herniated disc
Other
List any medications or supplements you are currently taking.
What are your primary goals or expectations for this session?
*
How would you describe your current physical activity level?
*
Sedentary (little or no exercise)
Light activity (light exercise/sports 1-3 days/week)
Moderate activity (moderate exercise/sports 3-5 days/week)
Very active (hard exercise/sports 6-7 days/week)
Other
Have you previously received lower back muscle release or similar treatments?
*
Yes
No
Is there anything else we should know about your health or comfort during the session?
Signature (please sign to confirm your consent)
*
Submit Intake Form
Submit Intake Form
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