Where is your pain located?
Head and Migraine (Cervical/Thoracic)
Shoulder
Abdomen/Torso
Low Back/Pelvic
Hips/Groin
Leg/Knee
Foot/Ankle
Other
Where is your pain strongest?
Lower back
Middle back
Neck
Head
Shoulders
Arms
Buttocks
Legs
Knees
Feet
Other
How long have you experienced this pain?
1 month or less
1 - 6 months
7 - 12 months
1 year or more
How would you describe the pain?
Sharp
Burning
Cramping
Numbness or tingling
Radiating or throbbing
Shocking (quick jolts of pain)
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.
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 backward
While sitting
While lying down
While performing strenuous activity
What caused your pain or injury originally?
Not sure
Lifting something heavy
Vehicle crash or accident
Slip or fall
Traumatic injury
Normal wear and tear
Other
Have you been diagnosed with a specific condition?
Yes, I've been diagnosed by a physician
No, I have not been diagnosed by a physician
Have you undergone any of the following?
CT Scan
MRI
X-Ray
Nerve Conduction Study-EMG
Other
None of the above
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How did you hear about us?
Facebook
Google
Family/friend
TV
Medical Provider
Previous Patient
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PPO
HMO
LOP
PIP
Worker's Comp
Medicare
Medicaid
Self-pay
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Diagnose My Pain