Where are you experiencing pain? (Choose all that apply) *

Cervical (neck) region

Thoracic (mid-spine) region

Lumbar (lower back) region

Shoulders or Arms

Hip, Buttocks, or Legs

Joints (wrists, elbows, knees, ankles, etc.)

Other

How long have you been experiencing pain? *

0 to 6 months

6 months to 1 year

More than 1 year

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 or what position I'm in.

Describe any pain-related symptoms (Choose all that apply) *

Stabbing, shooting, or radiating pain

Tenderness, throbbing, or dull aching

Numbness, tingling, or pins-and-needles sensations

Burning or stinging

Stiffness or reduced range of motion

Localized swelling or global inflammation

Muscular cramps or spasms

Progressive weakness

Lack of balance or coordination

Difficulty walking, bending, sitting, or rotating the spine

"Crunching" or grinding sensations in joints

Other

How did your pain begin? *

Not sure

Lifting something heavy

Vehicle crash or accident

Slip or fall

Traumatic Injury

Other

Which of the following treatments have you tried? *

Self-care (rest, over-the-counter medications, ice & heat application, etc.)

Alternative Therapy (Yoga, Acupuncture, Massage Therapy)

Chiropractic Care

Physical Therapy

Pain Management (prescription strength pain medication, joint or spine injections, etc.)

Surgical Intervention

Other

Have you received diagnostic imaging for this concern?

X-ray

MRI

CT Scan

SPECT Scan

Ultrasound

EMG/ NCV Studies

No, I haven’t

If you have received an MRI, how long ago was it?

0 to 6 months

6 months to 1 year

1 to 2 years

2 years or more

What type of insurance do you have? *

Who is your primary insurance carrier? *

Do you have out-of-network benefits? *

Yes

Not Sure

First Name

Last Name

Phone *

Email *

Location Preference

Best Time to Call

Anything else you would like for us to know?

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