Which of the following describes your symptoms? *

Pressure in mid-back, mid-back may feel stuck, Popping sensation when waking up and stretching

Low-back pain with any movements of the spine, Tightness in one side of the lower back, Stiff and achy lower back in the morning or night

Shooting pain from the low back into the glute region, Fire like pain going down the leg

Widespread back pain, The presence of a hump in the middle or upper back

Rate the severity of your pain, on a scale from 1-10.

1-3

4-6

7-8

9-10

Is the pain sharp, shooting, burning, or throbbing?

Sharp

Shooting

Burning

Throbbing

How long have you had this pain?

A few days

A few weeks

Less than a year

1-2 years

3+ years

Do you remember a specific incident that caused this pain?

Yes

No

When was the last time you saw a chiropractor?

Never

In the last few months

In the last year

More than a year ago

Great! Now let us know where to send your results.

First Name *

Last Name *

Phone *

Email *

By submitting, you confirm that you consent to receive SMS and email messaging from Optimize Chiropractic using the contact information you provide. Msg & Data rates may apply. Reply STOP at any time to unsubscribe.