Registration Form - The PainWISE Healthy Spine Program

Healthy Spine Registration Form

We look forward to supporting you in the Healthy Spine Program!

Please complete this registration form so that we can understand more about your back pain and enrol you into our Healthy Spine Clinic!

After you submit this form, you will be able to book into our Healthy Spine Clinic!

Come and collect your PainWISE Healthy Spine Toolkit!
Learn scientifically proven ways to achieve a healthy spine!
Earn rewards while you achieve pain relief!

Begin your pain relief journey TODAY!

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Your Personal Information

Your Name(Required)

First Name Surname

Employee Number(Required)

Which area do you live in?(Required)

City State / Province / Region ZIP / Postal Code

Your Email Address(Required)

Enter Email Confirm Email

Whatsapp Mobile (Please include your country code, e.g. +60 12 234 2345)(Required)

A little bit about you

To help us to prepare for your initial appointment with us, please tell us a bit about the pain you experience!

List your known health conditions (E.g. High blood pressure, diabetes, osteoarthritis etc.)(Required)

If you do not suffer from any health conditions, please type "NIL"

How long have you had pain in your back/spine?(Required)

1-3 months

3-6 months

Beyond 12 months

How often do you experience back/spine pain?(Required)

Every day

1-2 times a week

1-2 times a month

Which part of your back/spine is painful?(Required)

Tick all your affected areas

Neck

Shoulder

Upper back

Middle back

Lower back

What other body areas are affected because of your back/spine pain?(Required)

Tick all your affected areas

Pain also goes down my arms

Pain also makes my head hurt

Pain also goes down my leg(s)

Pain also goes to my waist area

Pain affects my hips

Pain makes my neck feel tight and painful

No other areas are affected

Are there other areas affected that you feel pins-and-needles or tingling in?(Required)

Tick all your affected areas

Arms

Fingers

Legs

Feet

I do not experience any pins-and-needles or tingling in any other areas

Are there other areas affected that you feel numb (i.e. loss of sensation) in?(Required)

Tick all your affected areas

Arms

Fingers

Legs

Feet

I do not feel numb in any other areas

Have you had any of the following concerns:(Required)

Tick all your affected areas

Recent or frequent falls

Unexplained fever

Waking up from pain

Unexplained weight loss

Pain when lying down

Loss of hand coordination

Past cancer and now in remission

I do not have any of the above mentioned concerns

On a scale of 1 to 10, on average in the past week, what is the LEAST back/spine pain you experienced?(Required)

On a scale of 1 to 10, on average in the past week, what is the WORSE back/spine pain you experienced?(Required)

List the medicines you normally take for your back/spine pain and how often you take them?(Required)

Do you find the medicines you take effective?(Required)

No, they do not work for me

No, I prefer not to take any medicines if I can avoid

Some of the time

Most of the time

All the time

Have you had surgery before for your back/spine pain?(Required)

Yes

If YES, what type of surgery have you had? (Describe as best as you can)(Required)

If NO, please type "NIL SURGERY"

What else have you found helpful for your back/spine pain?(Required)

Please choose as many as you have found helpful.

Heat therapy

Cold therapy

Heat creams

Massage

Exercise

Lying down

Physiotherapy

Chinese medicine

Acupuncture

Others

If you listed 'Others' above, please give more information

What are the things you would like to do if your back/spine pain was better?

On a scale of 1 to 10, how interested are you in understanding more about your back/spine pain and learn new ways of achieving pain relief?

Terms and Conditions of Participation(Required)

The Healthy Spine Program is operated by PainWISE Pty Ltd, Australia.

This is a voluntary education program to educate you about back pain and ways to maintain a healthy spine. It does not include clinical advice for your health situation and is not a diagnostic program, and you should see your medical practitioner or other health adviser for advice in your situation.
You can stop your participation in the Healthy Spine Program at any time.
Terms and conditions for the online Healthy Spine Program can be found here: https://healthyspine.com.au/terms-and-conditions-of-participation

I agree to the terms and conditions.