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
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
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
Very committed
Somewhat committed
Neutral
Not ready to commit yet
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Which insurance (if any) do you have? (We are NOT a Medicaid provider)
Aetna
Blue Cross/Blue Shield
United Healthcare
Cigna
Aetna
Humana
Medicaid
Medicare
Cash/Out of pocket
Other
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