Back and Neck evaluation

If you are dealing with persistent back or neck pain, this evaluation helps determine whether the Back & Neck Reset Protocol is an appropriate next step.
This therapeutic program combines:
• structural movement assessment
• targeted yoga therapy
• shockwave therapy when appropriate
• a personalized home practice
This form helps identify the root cause patterns contributing to your pain.
Completion time: 2–3 minutes

Click the button below to start.

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Question 1 of 14

Full Name

Paragraph answer

Question 2 of 14

Email Address

Paragraph answer

Question 3 of 14

Contact Number

Paragraph answer

Question 4 of 14

1. Where is your primary pain located?

A

Neck / base of skull

B

Upper back / shoulder blades

C

Mid back / ribs

D

Low back

E

Pain moves between multiple areas

Question 5 of 14

2. How long has this been affecting you?

A

Less than 2 weeks

B

2 weeks – 3 months

C

3–12 months

D

1–5 years

E

More than 5 years

Question 6 of 14

3. When is your pain worst?

A

Sitting

B

Sleeping

C

Driving

D

Exercise

E

Constant

Question 7 of 14

4. Which activities feel restricted because of your pain?

A

Turning your head

B

Reaching overhead

C

Twisting

D

Standing for long periods

E

Sitting for long periods

Question 8 of 14

5. What does the pain feel like?

A

Tightness or restriction

B

Deep aching

C

Sharp pain during movement

D

Stiffness

E

Nerve sensations (tingling / burning)

Question 9 of 14

6. Have you tried any of the following?

(Select all that apply)

A

Physical therapy

B

Chiropractic care

C

Massage therapy

D

Stretching / yoga

E

Strength training

F

None

Question 10 of 14

7. Did any of these approaches fully resolve the issue?

A

Yes, temporarily

B

Helped but pain returned

C

Minimal improvement

D

No improvement

Question 11 of 14

8. Have you experienced any of the following recently?

(Select all that apply)

A

Major accident or trauma

B

Loss of strength in arm or leg

C

Loss of bowel or bladder control

D

Fever or unexplained weight loss

E

None of the above

Question 12 of 14

9. Are you able to participate in gentle movement and therapeutic exercise?

A

Yes

B

Yes, with some limitations

C

Not currently

Question 13 of 14

10. If a targeted therapeutic program could significantly improve your pain, would you be open to working together over a 6–8 week period?

A

Yes

B

Possibly

C

Not sure

Question 14 of 14

11. Programs typically range from $1,000–$1,600 depending on the treatment plan.
If the evaluation suggests the protocol could help you, are you open to this level of investment?

A

Yes

B

Possibly

C

No

Confirm and Submit

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Back and Neck evaluation

Click the button below to start.

Full Name

Email Address

Contact Number

1. Where is your primary pain located?

2. How long has this been affecting you?

3. When is your pain worst?

4. Which activities feel restricted because of your pain?

5. What does the pain feel like?

6. Have you tried any of the following?

7. Did any of these approaches fully resolve the issue?

8. Have you experienced any of the following recently?

9. Are you able to participate in gentle movement and therapeutic exercise?

10. If a targeted therapeutic program could significantly improve your pain, would you be open to working together over a 6–8 week period?

11. Programs typically range from $1,000–$1,600 depending on the treatment plan.If the evaluation suggests the protocol could help you, are you open to this level of investment?

Confirm and Submit

11. Programs typically range from $1,000–$1,600 depending on the treatment plan.
If the evaluation suggests the protocol could help you, are you open to this level of investment?