Back Injuries

In order for us to carry out a quick assessment of your injury please complete and submit the following quick form:

Is the injury:	Sport related Work related
Where on your back does it hurt?
Is the injury:	Acute (felt specifically whilst exercising or completing daily task) Chronic (slowly getting worse over time)
Can you describe the pain with one of the following:	Sharp Electric type pain Numbness or specific point ache (tooth ache in the body/muscle)
Did you ever hear a crack pop or other audible tone from the body part?	Yes No
Is normal range of movement affected?	Yes No
Is there any bruising, swelling or discolouration?	Yes No
Were you able to continue with sport or activity or did you have to stop and rest?	Able to continue Had to stop
Do you suffer from headaches as a direct result of back tension/pain?	Yes No
Any referred pain in the arm/hand?	Yes No
Any referred pain/numbness in the leg?	Yes No
Name:
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Postcode (first 3/4 digits):
Phone (optional):	form generator
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