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
Elbow
Wrist
Legs
Headache
Feet
Ankle
Balance Issues
Hip
Sciatica
Neuropathy
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
Have you had any surgeries to your existing pain or any other pain condition?
Yes
No
What areas of your life are affected by the pain? Choose all options that apply.
Maintaining a safe environment
Communication with colleagues and/or loved ones
Breathing
Eating & drinking
Washing & dressing
Mobilization
Working & playing
Expressing sexuality
Sleeping
Parenting
Finances
Household chores
Self worth/value
Physical well-being
Emotional health
My Everyday tasks/life is affected
How committed are you to fixing your pain TODAY?
Very committed
Which insurance (if any) do you have? (We are NOT a Medicaid provider)
Aetna
Zip Code
First Name
*
Last Name
*
Email
*