Lower Back Pain Rehabilitation Self Referral

REFERRING ONTO THE LOWER BACK PAIN REHABILITATION COURSE?

Please fill in your details on the self referral form, and a member of our team will be in contact with you shortly.

    Your Full Name (required)

    Your Date of Birth (required)

    Your Email

    Your Telephone (required)

    Has any health care professional ever advised you not to exercise? Please state yes or no. (required)

    Are you currently active? Please give details.(required)

    Are you off work, or have you recently had time off work due to your back pain? Please give details.(required)

    Have you had a diagnosis from a health care professional? Please give details.(required)

    Do you know the cause of your back pain? Please give details.(required)

    How long have your suffered with your back pain?(required)

    When is your back pain more prominent? Please give details.(required)

    Does your back pain prevent you from doing everyday normal activities such as cleaning, cooking, walking etc? Please give details.(required)

    On a GOOD day how would you rate your level of pain between 0 and 10? 0 being no pain at all, 1-3 being mild, 4-6 moderate, 7-9 being severe, and 10 being the worst imaginable pain.(required)

    On a BAD day how would you rate your level of pain between 0 and 10? 0 being no pain at all, 1-3 being mild, 4-6 moderate, 7-9 being severe, and 10 being the worst imaginable pain.(required)

    Do you take any medication for your back pain? Please give details.(required)

    By completing this form I agree to the terms and conditions of use at Roefield Leisure and understand that the centre may contact me via email, SMS, telephone or post for the purpose of delivering the services to me. The information collected on this form (including but not limited to my personal data) will be used by Roefield Leisure and third parties approved by Roefield Leisure to enable the delivery of services.

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