Where are you experiencing pain/discomfort?
On a scale of 1-10, how would you rate your pain? (1 being hardly any pain, 10 being unbearable)
1
2
3
4
5
6
7
8
9
10
Describe your Pain/Discomfort
Sharp
Stiffening
Numbness / Tingling
Burning
Aching
It's Something Else
How long have you been in pain?
0-3 Months
3-12 Months
1-3 Years
3 Years +
Have you been seen by a doctor for this problem?
Chiropractor
Pain Management
Neurologist
Orthopedic Surgeon
General/Family Doctor
Other
None
What have you tried in the past that has not corrected your problem?
Pain Prescription
Steroid Injections
Advil, Tylenol or Aspirin
Physical Therapy
Surgery
Other
What aspects of your life are being negatively impacted?
Work
Marriage/Relationships
Ability to Exercise
Sleep
Mood
On a scale of 1-5, How important is it to get this problem corrected?
1
2
3
4
5
First Name
*
Last Name
*
Phone
*
Email
*