Pain Evaluation Test

Your Contact Information:

MM slash DD slash YYYY

Please answer the following questions:

Please check any or all of the primary pain you are experiencing:(Required)
How long have you had the pain?(Required)
Check any or all of the modifiers that most closely describe your pain.(Required)
Which best describes the frequency of your pain?(Required)
Have you already contacted a doctor about your pain?(Required)
Have you had back surgery?(Required)
Are you scheduled for back surgery?(Required)
Have you been diagnosed with any of the following:(Required)
My condition and pain has affected my activities as follows:(Required)
Which more closely describes your pain level by time of day:(Required)
What is the best time to contact you?(Required)
If there is a way to relieve your pain with one of our advanced non-surgical treatment programs, are you interested in scheduling a consult with our doctor?(Required)

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