Your next step is to complete the detailed intake form below.
This form is very important because your Custom Recovery Blueprint will be built around your symptoms, MRI findings, pain triggers, limitations, goals, injury history and current recovery stage.
Please take your time and answer as clearly as possible. The more detail you give, the better your personalized recovery roadmap can be.
After you submit the form, your Custom Recovery Blueprint will be personally reviewed and built by Mike.
Delivery time: 5 to 7 business days after intake form submission.
Important:
PainFreeBackNow is recovery coaching and education. It is not medical diagnosis, emergency medical care or a replacement for your doctor. If you have bladder or bowel issues, numbness around the private area, foot drop, rapidly worsening weakness, paralysis, or any urgent neurological symptoms, seek medical care immediately before starting any program.
CUSTOM RECOVERY BLUEPRINT INTAKE FORM
1. Full name
2. Email address
3. Instagram username
4. Age
5. Country
6. Height and weight
7. What is your diagnosis?
Example: L4-L5 disc bulge, L5-S1 herniation, sciatica, degeneration, stenosis, post-surgery, etc.
8. Do you have an MRI report?
Yes / No
9. If you have an MRI report, please send it to me after submitting this form.
After you complete this form, send your MRI report, screenshots or medical documents to me by Instagram DM or email.
Instagram: @painfreebacknow
Email: support@painfreebacknow.com
Write your full name in the message so I can match it with your intake form.
10. When did your symptoms start?
11. How did the injury or symptoms begin?
12. What symptoms do you currently feel?
Lower back pain, buttock pain, hip pain, leg pain, calf pain, foot pain, numbness, tingling, burning, weakness, stiffness, etc.
13. Which side is affected?
Left / Right / Both sides / Symptoms change sides
14. Where exactly do you feel symptoms?
Describe the path of pain or numbness. Example: lower back to buttock to calf to foot.
15. Rate your pain from 0 to 10 on an average day.
16. Rate your pain from 0 to 10 during a flare-up.
17. What makes your symptoms worse?
Sitting, bending, walking, standing, driving, sleeping, lifting, twisting, coughing, sneezing, training, etc.
18. What makes your symptoms better?
Walking, lying down, heat, medication, specific positions, stretching, exercises, etc.
19. How long can you sit before symptoms increase?
20. How long can you stand before symptoms increase?
21. How long can you walk before symptoms increase?
22. Can you bend forward comfortably?
Yes / No / Limited / Painful / Fearful
23. Can you sleep normally?
Yes / No
24. If no, what position hurts and what position helps?
25. Do you have any bladder or bowel control problems?
Yes / No
26. Do you have numbness around the private area or saddle area?
Yes / No
27. Do you have foot drop or difficulty lifting your foot/toes?
Yes / No
28. Do you have worsening leg weakness?
Yes / No
29. Have you had spine surgery before?
Yes / No
30. If yes, what surgery and when?
31. What treatments have you already tried?
Physiotherapy, chiropractic, injections, medication, massage, decompression, YouTube exercises, rest, surgery, etc.
32. What exercises are you currently doing?
33. Which exercises or movements flare you up?
34. What is your current activity level?
Inactive / Walking only / Light training / Gym / Sport / Physical work
35. What is your job and how does it affect your back?
Desk work, driving, standing, physical work, lifting, etc.
36. What are your biggest daily limitations right now?
37. What are your top 3 recovery goals?
Example: sit pain free, bend forward, return to gym, work full day, sleep normally, play with kids, run, lift weights.
38. What are you most afraid of right now?
39. What does your ideal life look like 6 months from now?
40. Are you willing to follow the plan exactly and avoid random exercises while following your blueprint?
Yes / No
41. Do you understand that this is a one-time personalized plan and does not include weekly Zoom calls, daily WhatsApp support or ongoing coaching?
Yes / No
42. Anything else i should know before building your Custom Recovery Blueprint?