On a scale of 1-10, one being hardly any pain and ten being excruciating, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
Where is the source of your pain? Choose all options that apply.
Neck
Back
Knee
Shoulder
Arms
Legs
Headache
Other
What type of doctors have you seen? Choose all options that apply.
Chiropractor
Pain Management
Neurologist
Orthopaedic Surgeon
General/Family Doctor
Other
None
How did the pain begin? Choose all options that apply.
Accident at home
Vehicle accident
Accident at work/work related
It just began
After surgery
Came on gradually
Sports related
Other
What areas of your life are affected by the pain? Choose all options that apply.
Maintaining a safe environment
Communication
Breathing
Eating & drinking
Washing & dressing
Mobilization
Working & playing
Expressing sexuality
Sleeping
Daily parenting
Finances
Household chores
Self worth/value
Physical well-being
Emotional health
Other
How committed are you to fixing your pain TODAY?
Very committed
PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I will NOT miss my appointment once it is scheduled and confirmed because I respect your time and I understand it's not fair to others who would schedule in my place if I don't show up.
*
Yes
No
PLEASE ACKNOWLEDGE THE FOLLOWING STATEMENT: I understand that the office is located at 4947 Library Road, Bethel Park 15102.
*
Yes
No
First Name
Last Name
Email
*