Get Out of Back Pain Intake Assessment Get Out of Back Pain Intake Assessment Name Name First First Last Last Address PREFERRED DAYTIME PHONE: This is a Home Cell Work Cell PREFERRED EVENING PHONE: This is a Home Cell Work Cell Email TODAY’S DATE: BIRTH DATE (Month, Day or MM/DD): Let’s talk about your back and neck pain. What is your typical pain level on a scale of 1-10 where 1 is almost none and 10 is off the charts? 0 1 2 3 4 5 6 7 8 9 10 What are your current challenges with your back? How does having back pain get in your way? What is that like for you? Are there any things you have stopped doing as a result of having back or neck pain? Are other people in your life affected by your back pain? What if anything have you tried to get rid of your pain? Did it help? Instead of your back being the way it is, what would you like instead? If you said, “I don’t want to be in pain” or “out of pain”, please think deeper. Why? What, for you, is wrong with feeling pain? Do you have a vision of what you would like your life to be like? If your back were better, what might you be doing that you are not doing now? Why is that important to you? Pretend it’s 6 months from now. What would you like to be saying about your back and neck pain? Anything else you want to tell me or that you want me know about your back/neck/shoulder? If you are human, leave this field blank. Submit Δ
