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SPEAK WITH AN EXPERT

Now seeing patients in NYC & CT

Pain Assessment Tool

Help us help you by filling out this pain assessment tool. Our back pain experts will use this information to assist you in finding effective treatment for any condition you may have.

Step 1: Tell us where it hurts
Please select your areas of pain.
- Lower Back
- Middle Back
- Neck
- Shoulders
- Arms
- Buttocks
- Legs
Where is the 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
Have you been diagnosed with a specific condition?
- Yes, I have been diagnosed by a physician
- No, I have not been diagnosed by a physician
Step 2: Describe your pain for us
How would your describe your pain or symptoms?
- Sharp
- Burning
- Cramping
- Numbness & tingling
- Radiating (throbbing)
- Shocking (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'm doing or what position I'm in.
Step 3: Tell us more about your symptoms
When is your pain at its worst? (Choose all that apply)
- In the morning after waking up
- While standing or walking
- While bending backwards
- While sitting
- While lying down
- While performing strenuous activity
When does your pain feel better?
- In the morning after waking up
- While standing or walking
- While bending backwards
- While sitting
- While lying down
- While performing strenuous activity
What caused your pain originally?
- Not sure
- Lifting something heavy
- Vehicle crash
- Slip or fall
- Traumatic injury
- Leaning forward
- Other
Step 4: Tell us about your past treatment
Have you undergone any of the following?
- CT Scan
- MRI
- Myelogram
- Viscogram
- X-Ray
- Nerve Conduction Study
- Other
- None
STEP 5: GET YOUR RESULTS NOW
First Name*
Last Name*
Email*
Phone*
Insurance
Comments
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Jenkins Neurospine gives every back patient access to a world-leading spine surgeon, supported by a 360-degree clinic specializing in pain management, imaging, and more.

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Locations

New York, NY

65 East 96th Street, Suite 1B

New York, NY 10128

Cos Cob, CT

31 River Road Suite 100

Cos Cob, CT. 06807

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