Pain Evaluation Test Your Contact Information:First Name(Required) Last Name(Required) PhoneDate of Birth MM slash DD slash YYYY E-Mail Please answer the following questions:Please check any or all of the primary pain you are experiencing:(Required) Headache Neck Low Back Buttocks Hip Leg Calf Foot Toes Other (Face, Torso, etc.) How long have you had the pain?(Required) Less than a month More than 6 weeks More than 6 months More than 1 year Check any or all of the modifiers that most closely describe your pain.(Required) Dull Sharp Burning Tingling Shooting Numbness Throbbing Which best describes the frequency of your pain?(Required) Intermittent (0-25% of day) Occasional (26-50% of day) Frequent (51-75% of day) Constant (76-100% of day) Have you already contacted a doctor about your pain?(Required) Yes No Have you had back surgery?(Required) Yes No Are you scheduled for back surgery?(Required) Yes No Have you been diagnosed with any of the following:(Required) Disc Herniation Disc Bulge Sciatica Spinal Stenosis Disc Degeneration Spondylolisthesis Abnormal Curvature (Scoliosis/Lordosis/Kyphosis) My condition and pain has affected my activities as follows:(Required) Pain Sitting Pain Standing Trouble Walking Interrupted Sleep at Night Decreased Activities Decreased Pace Which more closely describes your pain level by time of day:(Required) AM PM Both When was the last time you felt really great?(Required)When is your pain at its worst? Describe how you feel and are affected:(Required)What is the best time to contact you?(Required) Morning Afternoon Evening 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) YES NO One last thing please. Thank you for visiting! How did you hear about us? Δ
