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Tell Us About Your Pain

Please Fill Out Our Pain Assessment Form Below

Pain Assessment Progress

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Tell Us About Your Pain
Where 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 Us
How 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 Treatment
Have you undergone any of the following?
- CT Scan
- MRI
- X-Ray
- Nerve Conduction
  Study
- Other
  (Please Explain)
- None
Other Explanation

What’s your insurance plan?*
If other, please tell us about your insurance plan:

Personal information
First Name**
Last Name**
Email**
Phone**
*
Comments

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KEYSTONE PHYSICAL MEDICINE

420 W. Main St. #206
Boise, Idaho 83702

(208) 426-9200

HOURS OF OPERATION:

Monday - Thursday

7:00AM - 10:30AM & 11:30AM – 4:00PM

Friday 7:00AM - 11:00AM

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Keystone Physical Medicine

2122 W Everest Lane
Meridian, Idaho 83646

(208) 343-2770

HOURS OF OPERATION

Monday – Thursday
9:00AM – 4:00PM

Friday, Saturday, and Sunday
Closed

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(208) 343-2770