Back Pain Assessment: Intake Form

This service is offered in English only. It has three steps: this form, one live video call, and my written report. This form starts the process. Not every question will fit your situation, and that is fine. Please give as much detail as you can. Questions marked * are needed. There is no auto-save, so please do not close this page until you submit. You can also download the Word version.

1. Safety check

Please read this first. This service is education, not medical treatment.

A doctor has checked my back pain, found no serious cause, and said gentle exercise is safe for me. * Yes No, or I am not sure

Warning signs. Do any of these apply to you now, or have they started since a doctor last checked your back?

A recent serious injury (fall, car accident)
Unexplained weight loss with the pain
Fever, chills, or night sweats with the pain
A new problem controlling your bladder or bowels
Numbness around your groin or bottom
Severe or growing numbness or weakness in a leg
Pain that gets worse at rest or at night
A past or current cancer, or weak bones (osteoporosis)

Do any of these apply to you? * No, none of these apply to me Yes, one or more apply to me

Please see a doctor first. This service is not suitable until a doctor has checked your back. Nothing you typed has been sent. You are welcome to come back after you have been cleared. If you chose an answer by mistake, change it above.

Type your full name to confirm the first answer *

2. Your details

Full name *

Email *

Your time zone * For example UTC+3 or GMT-5. We fill in a guess; please check it. We will agree a call time by email.

Country and city *

Age * You must be 18 or older.

Gender (optional)

Height in cm (optional)

Weight in kg (optional)

3. About your pain

Pain scale: use the same guide for the three number questions below.

Number	What it is like
0	No pain.
1–2	Mild. You notice it only if you think about it. It does not stop any activity.
3–4	Moderate. You notice it often and it is distracting, but you can still do your usual activities.
5–6	Strong. It is hard to ignore. It interrupts some activities, or you avoid some.
7–8	Severe. It is hard to think about anything else. You cannot do many usual activities.
9	Very severe. You can barely do anything and cannot concentrate.
10	The worst pain you can imagine. You could think of nothing else and would want urgent medical help.

If your pain is very severe and new, please see a doctor first. Think about your usual back pain over the last 4 weeks.

4. Triggers, tolerances, and your approach

Major triggers: which movements or positions bring on your pain? *

Tolerances: what can you do comfortably, or what relieves the pain? *

Where is the pain, and does it move? *

How would you describe your personality and how you handle setbacks? (optional)

5. Medical history and treatments

History relevant to your back pain *

Current training or health, and your goals (optional)

Treatments you have tried *

Other treatment details (optional)

6. What to expect, and consent

Steps: (1) this form; (2) one live video call of about 90 minutes, where we talk and you try a few simple movements on camera (you need a camera and a hard chair). I am in Australia, so we will agree a time by email that suits us both, wherever you live, and you may need to be flexible; (3) my written report by email. That is all: there is no ongoing coaching and no further email advice. After I send your report I delete your answers and any recording. Possible risks: you may feel more sore for a day or so, and rarely, briefly light-headed. You can pause or stop at any time.

Needed to submit:

I understand this is a single educational service with three contacts: this form, one video call, and one emailed report. It does not include ongoing coaching or further email advice. I am responsible for how I use the plan. I understand Ian Browne is an educator, not a doctor or physiotherapist. This does not create a doctor–patient relationship and does not replace my own doctor’s advice. I understand the risks above. I will stop and get medical help if something feels wrong, and I will not hold Ian Browne responsible for results of using this information. I have read the Disclaimer and Privacy Policy, and I agree that my answers are sent to Ian Browne by email.

Optional (saying no does not change your assessment):

If my case teaches something useful, a version with my name, contact details, and other identifying details removed may be kept to help wider research into back problems. Once details are removed it cannot be traced back to me. I can change my mind by email before then. Ian may email me once, about 3–4 months after my report, to ask how I am going. I can ignore it. Until then Ian keeps only my name and email. Ian may record part of the video call if needed to review a movement. Otherwise calls are not recorded.