Where is your pain located?
Head & Neck
Back & Spine
Knee, Leg, & Foot
Foot & Ankle
Shoulder & Arm
Abdomen/Torso
Other
Where is your pain strongest?
Lower back
Middle back
Neck
Head
Shoulders
Arms
Buttocks
Legs
Knees
Feet
Other
How long have you been experiencing pain?
1 month or less
1 - 6 months
7 - 12 months
1 year or more
Are you always in pain?
Yes, I'm in constant pain that may worsen depending on the activity I'm doing.
No, it comes and goes depending on what activity I'm doing or what position I'm in.
Do you have any of the following symptoms?
Pins and Needles Feeling
Numbness
Tingling Sensations
Progressing Weakness
Loss of Coordination
None
When is your pain at its worst?
In the morning after waking up
While standing or walking
While bending backward
While sitting
While lying down
While performing strenuous activity
When does your pain lessen or disappear?
In the morning after waking up
While standing or walking
While bending backwards
While sitting
While lying down
While performing strenuous activity
What caused your pain originally?
Not sure
Lifting something heavy
Vehicle crash or accident
Slip or fall
Traumatic injury
Leaning forward
Normal wear and tear
Other
Have you undergone any of the following treatments?
CT Scan
MRI
X-Ray
Nerve Conduction Study-EMG
Other
None of the above
If other, please tell us about any past treatments:
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How did you hear about us?
Insurance Type
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Self-Reported Insurance Type
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