• Restore Haus 8 Week Individual Low Back Rehabilitation Program Intake Form

    Complete this form to help us understand your symptoms, medical history, and goals for your personalized 8-week program.

  • Basic Information

  • Format: (000) 000-0000.

  • Functional Readiness

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

  • Symptom History

  • 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 2)*

  • Program Commitment

  • Can you attend 2 in-person sessions per week for 8 weeks?*
  • Can you commit to attending the weekly online exercise session for the duration of the program?*

  • This rehabilitation program requires consistent participation to achieve the best outcomes. If you're unable to commit to the recommended exercise schedule at this time, you're welcome to apply again when your availability changes

  • Emergency Contact Info

  • 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
  • Should be Empty: