First Name *

Last Name *

Phone *

Email *

1. What is the level of pain you are experiencing? (10 being the most severe) *

0–2 (Minimal)

3–4 (Mild)

5–6 (Moderate)

7–8 (Severe)

9–10 (Very Severe)

2. Where is the source of your pain? (Check All That Apply) *

Feet or toes

Hands or fingers

Lower legs

Arms

Back

Knee

Neck

3. What type of pain are you experiencing? (Check All That Apply)

Tingling or pins & needles

Burning or sharp sensations

Numbness

Loss of balance

Sensitivity to touch

4. What type of doctors have you seen for your pain? (Check All That Apply) *

Primary care physician

Neurologist

Pain management specialist

Orthopedic doctor

Chiropractor

Physical therapist

I have not seen a doctor yet

5. What medications or treatments are you receiving for your pain? (Check All That Apply) *

Prescription medications

Gabapentin / Neurontin

Steroid injections

Nerve blocks

Over-the-counter pain relievers

Supplements or vitamins

Physical therapy

Chiropractic care

None

6. How did the pain begin? (Check All That Apply) *

Gradually over time

After an injury

After surgery

I’m not sure

7. Have you had any of the following treatments/procedures? (Check All That Apply) *

Physical therapy

Chiropractic care

Steroid injections

Nerve blocks

Other injections

None of the above

8. Check any of the following tests you have had for this condition? (Check All That Apply)

X-rays

MRI

CT scan

Nerve testing (EMG / NCV)

Blood work

No testing

9. Have you had any surgeries related to your existing pain or any prior pain conditions?

Yes

No

10. Do you have any additional information about your pain you want us to know or any questions about treatment options we can help answer?

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