Back Pain Digital Assessment

The following form is an online digital assessment to help determine the root cause of your back pain.

It consists of 7 questions and should take less than 60 seconds to complete. Results will be available immediately upon completion.

How long have you been dealing with your back pain?

Less than 1 month

1-3 months

3+ months

Do you have digestive problems?

Acid Reflux (even if it controlled by medication or diet)

Abdominal pain

Bloating after eating or with certain foods

Loose stools or constipation

None of the above

How's your sleep?

I have trouble getting to sleep

I wake during the night and can't get back to sleep

I wake up feeling unrested

None of the above

How's your posture?

One shoulder is higher than the other (look in a mirror or have someone else check you)

One hip higher than the other

Back pain is one sided

I have other symptoms on the same side as the back pain (neck pain, headaches etc.)

None of the above

Do you have any scars anywhere?

Surgical scars or scars from accidents

Scars that are red/pink, raised, irritated, numb or “weird” feeling

None of the above

What have you tried so far to get relief from your back pain?

Stretching or exercise

Chiropractic care

Physical therapy

Pain killers or anti-inflammatory drugs

Injections or surgery

None of the above

How would you rate the pain? 1 (minimal) - 10 (extreme)

Thank you for filling out the assessment. Please enter your info below so we can you the results.

First Name

Phone *

Email *