• Restore Haus Remote Low Back Assessment & Exercise Plan Intake Form

    This assessment helps us understand your symptoms, movement patterns, and goals so we can provide individualized exercise recommendations and next steps.

  • Basic Information

  • Functional Readiness

  • Are you able to comfortably get up and down from the floor independently without assistance?*
  • What is your biggest limitation?*

  • Pain Profile

  • How long have you been experiencing low back pain?*
  • Have you received assessment or treatment from a healthcare professional for your low back pain?*

  • If you have not yet received a healthcare assessment for your low back pain, we recommend consulting an appropriate healthcare provider, particularly if your symptoms are severe, worsening, or associated with neurological symptoms.

  • Symptom Profile

  • How would you describe your low back pain over the past 3 months?*
  • If your symptoms travel below your knee, which of the following best describes your situation?*

  • Based on your response, Restore Haus recommends that you first consult an appropriate healthcare professional for assessment and diagnosis before participating in this program. Please do not continue with this form.

  • When do your symptoms typically feel worst?*
  • Do your symptoms tend to increase during periods of stress, poor sleep, anxiety, or when emotionally overwhelmed?*
  • How much does your low back pain interfere with your daily activities?

  • Health & Medical History

  • Have you experienced or do any of the following apply to you? (Select all that apply.)*

  • Based on your responses, this program is not appropriate for you at this time.

    For your safety, we recommend seeking appropriate medical care where necessary before participating in this program. If your circumstances change and the program becomes appropriate for you in the future, you're welcome to complete the intake form again.

  • Are there any medical conditions, injuries, surgeries, or other health concerns you believe I should be aware of before developing your exercise program?*

  • Goals

  • What are your primary goals for this program? (Select up to 2)

  • Posture Photos

  • Photo submission instructions:

    Please upload clear full body (head to toe) standing photos from the front, side, and back.

    Wear clothing that allows your posture and body position to be seen clearly.

    Stand naturally with your feet shoulder-width apart and your arms relaxed at your sides.

    Do not attempt to correct or change your posture for the photos.

    These images will be used for assessment purposes only.

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  • Movement Videos

  • Video submission instructions

    Please record and upload the following movement videos in a well-lit area with your full body visible throughout the recording.

    Move at a comfortable pace and only within a range that feels safe and tolerable. Some discomfort during movement may be expected and does not necessarily indicate harm. However, stop the movement if you experience severe pain, sharp or shooting pain, significant increase of symptoms, dizziness, loss of balance, or any symptom that feels unsafe.

    If you are unable to complete a movement due to symptoms, skip the movement and indicate this later in the form.

    These videos will be used to assess your movement patterns and current functional capacity.

     

  • Upload a File
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  • Upload a File
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  • Upload a File
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  • Acknowledgement & Consent

  • Please review the Restore Haus Waiver and Informed Consent Agreement before proceeding.

    Click here to view the waiver.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year
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