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?
Have you been diagnosed with a specific condition?
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STEP 2:
DESCRIBE YOUR PAIN FOR US

How would your describe your pain?
Are you always in pain?
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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 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?
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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

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STEP 5:
GET YOUR RESULTS NOW

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