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* 1. Your name:

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* 2. Email Address:

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* 3. Are you under the care of a medical doctor, physical therapist, chiropractor, etc.? Please explain.

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* 4. Have you had spine or hip surgery?

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* 5. Check the boxes if you can do the following:

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* 6. Can you commit to doing exercises at home for 10 minutes per day during the course?

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* 7. What 3 things aggravate your back pain the most?

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* 8. What 3 things improve your back pain the most?

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* 9. How does back pain interfere with your lifestyle/mood/relationships?

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* 10. Request your class:

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