Condition Assessment Candidacy Check Tool Step 1: Tell Us About Your PainWhere is your pain? Lower Back Middle Back Neck Shoulders Arms Buttocks Legs Where is your pain strongest? Arms Buttocks Legs 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 How would you describe your pain? Sharp Burning Cramping Radiating (throbbing) Shocking (quick jolts of pain, with minor pain in-between) 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. Step 2: Tell Us About Your SymptomsDo you have any of the following symptoms? Pins and needles feeling Numbness Tingling sensations Progressing weakness Loss of coordination When is your pain at its worst? In the morning after waking up While standing or walking While bending backwards While sitting While performing strenuous activity When does your pain feel better? Sitting Down Standing up Walking Lying Down and Relaxing Leaning Forward Bending Backwards Step 3: Tell Us About Your Pain HistoryWhat caused your pain originally? Lifting Something Heavy Vehicle Crash Slip or Fall Traumatic Injury Leaning Forward Other If other please explain:Have you undergone any of the following? CT Scan MRI X-Ray Nerve Conduction Study Other If other please explain:Step 4: Tell Us About YourselfFirst Name*Last Name*Email* Phone*Insurance*Select your insurance typeAARPAetnaBeech StreetBlue Cross / Blue ShieldCaterpillarCignaCoventryHarvard PilgrimHumanaLiberty MutualUnited HealthcareMedicareSelf PayOtherCommentsEmailThis field is for validation purposes and should be left unchanged.
