STEP 1:
TELL US ABOUT YOUR PAIN

Please select your areas of pain:

Lower Back

Middle Back

Neck

Shoulders

Arms

Buttocks

Legs

Where is the pain strongest?
How long have you been experiencing pain?
NEXT STEP >>

STEP 2:
DESCRIBE YOUR PAIN FOR US

How would your describe your pain?
Are you always in pain?
<< GO BACK NEXT STEP >>

STEP 3:
TELL US MORE ABOUT YOUR SYMPTOMS

Do you have any of the following symptom? Choose all that apply.

Numbness

Tingling sensations

Progressing weakness

Loss of coordination

When is your pain at its worst? Choose all that apply.

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

What caused your pain originally?
If other, please explain:
<< GO BACK NEXT STEP >>

STEP 4:
TELL US ABOUT YOUR PAST TREATMENT

Have you undergone any of the following?

CT Scan

MRI

X-Ray

Nerve Conduction Study

Pain Management Injections

Other

<< GO BACK NEXT STEP >>

STEP 5:
GET YOUR RESULTS NOW

Comments