Pain Assessment Progress 12345 Tell Us About Your PainWhere does it hurt?*Choose all that apply: Lower Back Middle Back Neck Shoulders Arms Buttocks Legs Others Where Is the Pain Strongest?* Lower Back Middle Back Neck Shoulders How Long Have You Been Experiencing Pain:* 1 month or Less 1-6 months 7-12 months 1 year or more Describe Your Pain for UsHow would you describe your pain? Sharp Burning Cramping Throbbing Quick Jolts of Pain Are you always in pain?* Yes, I am in constant pain that worsens depending on what activity I am doing. No, it comes and goes depending on what activity I am doing. Do you have any of the following Symptoms? Pins and Needles Feeling Numbness Tingling Sensations Progressing Weakness Loss of Coordination None Tell Us About Your Past TreatmentHave you undergone any of the following? CT Scan MRI X-Ray Nerve ConductionStudy Other(Please Explain) None Other Explanation What’s your insurance plan?* If other, please tell us about your insurance plan: Personal informationFirst Name** Last Name** Email** Phone***Best Time to Call:MorningMiddayAfternoonComments Δ
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