Contact | Prescott, AZ | Natural Back Pain Relief LLC

First Name

Last Name

Email

Phone

Birthday

Height

Daily Activities

Lifting or carrying groceries

Moving a table, vacuuming

Climbing several flights of stairs

Walking several blocks

Exercise

No exercise program

One day a week

Two days a week

Three days a week

Four days a week

Five days a week

Six days a week

Seven days a week

Strength - How many times per week do you do strength-building exercises such as sit-ups, push-ups, or use strength training equipment?

None

Once a week

Twice a week

3+ times weekly

Stretching - How many times per week do you do stretching exercises to improve flexibility of your back, neck, shoulders, and legs?

None

Once a week

Twice a week

3+ times weekly

Activities – What activities do you prefer?

Referral source

Family member

Friend

Co-worker

Radio

Newspaper or Magazine Article

Internet or email

An Egoscue book

Physician or Medical professional

Do you diet often?

Yes

No

How much water a day do you drink?

24 oz or less

25-64 oz

65 oz or more

Do you participate in group workouts?

Yes

No

No but I’d like to

Do you work with a trainer?

Yes

No

No but I would like to

Have you been informed about your posture prior to coming to Egoscue?

Yes

No

Have you seen a physician or other healthcare practitioner about your particular symptom(s)?

Yes

No

Where are your symptoms located?

On average, how often do you get at least 7 - 8 hours of sleep each day?

Always or nearly always

Most of the time

Less than half the time

Seldom or never

Do you smoke?

Yes

No

Stress

Minor problems throw me for a loop

I find it difficult to get along with people I used to enjoy

Nothing seems to give me pleasure anymore

I am unable to stop thinking about my problems

I feel frustrated, impatient, or angry much of the time

I feel tense or anxious much of the time

Are you taking any medications?

Yes

No

Job description

How many visits have you made during the past 12 months to a doctor, emergency room, psychiatrist, chiropractor, or other healthcare professional?

When is the best time to contact you?

Morning

Afternoon

Evening

Contact preference

Text

Email

Phone

Other

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Liability Release and Client Consent to Service

Please be aware that Natural Back Pain Relief LLC is not a medical facility. A medical diagnosis will NOT be made, and we cannot accept or bill your insurance.

Client is responsible for correctly performing exercises given to them by Natural Back Pain Relief LLC. If any pain results during an exercise, client should stop and contact Natural Back Pain Relief LLC for an updated list of exercises (menu) or clarification on how to correctly perform the exercise. If new pain results after completing a menu, client is responsible for giving that feedback to Natural Back Pain Relief LLC before attempting the full menu again.

Payment of applicable fees is due in advance or at the time of your therapy session by credit card, check or cash.

Cancelation or rescheduling must be done more than 24 hours in advance of your appointment, else you will be charged for a full session.

Things to consider regarding the Prepaid Therapy Packages: The packages are designed to be completed within one (1) year. Should you decide not to continue your package, refunds will be prorated based on the current, individual session fee. Refunds for unused sessions will not be granted beyond one (1) year from your package initiation date. Natural Back Pain Relief LLC may choose to honor your unused sessions beyond one (1) year.

Note: Package and Individual session fees are subject to change at any time. The value of unused sessions beyond one (1) year may be adjusted to commensurate current fees.

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Multimedia & Publicity Privacy Release (Optional)

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I hereby grant Natural Back Pain Relief LLC, hereinafter referred to as the "NBPR", permission to use, reproduce, distribute, publicly perform and display, in any form now known or later developed, the items described below, hereinafter referred to as the "Materials."

This permission and release are for the following Materials:

Name

Voice

Photo or other visual likeness

Video or other audiovisual materials

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I understand that I am being asked to sign this release for the purpose of NBPR advertising and promoting NBPR's business. I understand that NBPR may use the Materials on NBPR's website, social media pages, in printed materials, or for other purposes.

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I release NBPR, as well as its agents, employees, owners, investors, licensees, and assigns from all claims I may have now or in the future for invasion of privacy, right of publicity, copyright infringement, defamation, or any other cause of action arising out of the use, reproduction, adaptation, distribution, broadcast, performance, or display of the Materials.

I waive any right to inspect or approve any works that may be created containing the Materials. I understand and agree that NBPR is and shall be the exclusive owner of all right, title, and interest, including copyright, in the Materials, and any advertising or promotional materials containing the Materials released hereunder.

I have fully read this release and understand that signing this release is voluntary and not a condition of service. I am fully familiar with its contents, and hereby agree to the terms above.

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By checking this box, I'm consenting to my selections in the above Privacy Release (optional)

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