Patient Form

Patient Screening Form

Note: At this time, our treatment program is exclusively available for individuals with lower back pain. Additional conditions may be considered in future expansions.

Patient Screening

First Name

Last Name

Email Address

Phone Number

Date of Birth

Gender

City

State

Do you speak English fluently?

Yes

No

Select all ethnicities that best describe you:

American Indian or Alaska Native

Asian

Hispanic, Latino or Spanish

Middle Eastern or North African

Native Hawaiian or Other Pacific Islander

White

Do you experience lower back pain?

Yes

No

How long have you been experiencing lower back pain?

Less than 3 months

3-5 months

6-12 months

More than 1 year

In the past 6 months, how often have you experienced pain?

Less than half the days

About half the days

More than half the days

Over the past week, what has been your average pain intensity on a scale of 0 to 10?

Is lower back pain your primary chronic pain complaint, meaning it is greater than any pain in other areas of your body?

Yes

No

Does your back pain radiate down your legs?

Yes

No

Is your back pain related to cancer?

Yes

No

Do you have any of the following conditions that may affect your ability to participate?

A medical condition that predisposes you to vertigo, nausea, dizziness or motion sickness

Hypersensitivity to flashing light or motion

Stereoscopic vision issues, digital eye strain or computer vision syndrome

Moderate to severe hearing loss that impedes the use of voice-overs

Major depressive disorder not controlled with medication

Other conditions that cause significant cognitive or emotional disability

None of the above

Do you have reliable access to Wi-Fi?

Yes

No

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Patient Screening Form

Patient Screening

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