What conditions are you suffering from?
What conditions are you suffering from?
On a scale of 1-10, one being hardly any pain and ten being unbearable, how would you rate your pain?
1
2
3
4
5
6
7
8
9
10
Describe your Pain/ Discomfort.
Sharp
Aching
Burning
Stiffening
Numbness & Tingling
Something Else
How long have you had this problem? *
0-3 Months
3-12 Months
1-3 Years
Over 3 Years
What type of doctors have you seen? Choose all options that apply.
Chiropractor
Pain Management
Neurologist
Orthopaedic Surgeon
General/Family Doctor
Other
None
What have you tried in the past that has not corrected your problem?
Aspirin, Tylenol or Advil
Steroid Injections
Prescription Pain
Physical Therapy
Surgery
Other
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
Working & playing
Expressing sexuality
Sleeping
Finances
Household chores
Self worth/value
Physical well-being
Emotional health
Other
What aspects of your life are being negatively impacted? *
Marriage/Relationships
Ability to Exercise
Work
Mood
Sleep
On a scale of 0 - 5 how important is it for you to get this problem corrected?
1
2
3
4
5
First Name
*
Last Name
*
Phone
*
Email
*
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