Back Care Questionnaire.
Please answer all questions.
Which programme attending?
*
Please Select
Online on demand membership
Live online via zoom
Face to face in The Studio
Which week are you on?
*
Week One
Week Six
What are your current pain levels?
*
Occasional
1
2
3
4
5
6
7
8
9
Constant
10
1 is Occasional, 10 is Constant
How many hours of sleep do you get at night?
*
1
2
3
4
5
6
7
8
9
1 is , 9 is
What is your current sleep quality like?
*
Very Good
1
2
3
4
5
6
7
8
9
Very Bad
10
1 is Very Good, 10 is Very Bad
What everyday activities do you currently struggle with?
*
Putting my socks on
Putting my coat on
Putting my seatbelt on
Getting out of bed in the morning
Doing the washing
Hoovering the house
Gardening
Sitting for periods of time
Standing for periods of time
Driving
Picking my kids up
Getting up after sitting
Any bending and lifting task
None of the above
Getting up and down from the floor
Other
Contact Details
Your Name
*
First Name
Last Name
E-mail
*
Date
*
-
Day
-
Month
Year
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