What are you dealing with?

Back pain

Sciatica

Both

How long has this been going on?

Under 3 months

3-12 months

1-3 years

3-5 years

5+ years

What does it stop you from doing right now? (pick up to 3)

Sleeping

Sitting / driving

Training / sports

Working

Kids - family

Walking

Traveling

Mood - confidence

What have you already tried? (check all that apply)

Physio

Chiro

Massage

Injections

Surgery (scheduled)

Stretching

Yoga

Rest / avoidance

Meds

Online programs

Nothing consistent

Why is this urgent now? (2–4 sentences)

Tell me as much as you can. I am selecting the person with the most need: What’s at stake if nothing changes?

What would success look like 90 days from now? (2–4 sentences)

Tell me as much as you can. I am selecting the person with the most need. Be specific: what can you do that you can’t do now?

Commitment check: what can you do daily for the next 30 days?

10 Min a day

20 Min a day

30 Min a day

Whatever it takes

Not sure I can do daily

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OK ☑️

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