Pain Evaluation Test Your Contact Information:First Name(Required)Last Name(Required)PhoneDate of Birth MM slash DD slash YYYY E-MailPlease 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 yearCheck any or all of the modifiers that most closely describe your pain.(Required) Dull Sharp Burning Tingling Shooting Numbness ThrobbingWhich 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 NoHave you had back surgery?(Required) Yes NoAre you scheduled for back surgery?(Required) Yes NoHave 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 PaceWhich more closely describes your pain level by time of day:(Required) AM PM BothWhen 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 EveningIf 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 NOOne last thing please. Thank you for visiting! How did you hear about us?Δ
