Where does it hurt? Choose all that apply.
Neck
Middle Back
Lower Back
Shoulders
Arms
Legs
Buttocks
Other
Where is the pain strongest?
Neck
Middle Back
Lower Back
Shoulders
Arms
Legs
Buttocks
Other
How long have you been experiencing pain?
1 month or less
1 - 6 months
7 - 12 months
1 year or more
Have you been diagnosed with a specific condition?
Yes, I have been diagnosed by a physician
No, I have not been diagnosed by a physician
How would you describe your pain?
Sharp
Burning
Cramping
Numbness & Tingling
Throbbing
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.
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 backwards
While sitting
While lying down
While performing strenuous activity
When does your pain feel better?
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
Slip or fall
Traumatic injury
Leaning forward
Other
Have you undergone any of the following treatments?
CT Scan
MRI
Myelogram
Viscogram
X-Ray
Nerve Conduction Study
Other (Please Explain)
None
If other, please tell us about any past treatments:
First Name
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Last Name
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How Can We Help?
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Spine
Orthopedic
Pain Management
Bariatric
Cosmetic
Gynecology
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Insurance Type
HMO
PPO
LOP
PIP
Worker's Comp
Medicare
Medicaid
Self-pay
Other
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