pain-assessment Pain Assessment Tool Step 1: Tell us where it hurtsPlease 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 usHow 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 symptomsWhen 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 treatmentHave you undergone any of the following? CT Scan MRI Myelogram Viscogram X-Ray Nerve Conduction Study Other None STEP 5: GET YOUR RESULTS NOWFirst Name* Last Name* Email* Phone*InsuranceSelect your insurance typeAARPAetnaBeech StreetBlue Cross / Blue ShieldCaterpillarCignaCoventryHarvard PilgrimHumanaLiberty MutalUnited HealthcareMedicareSelf PayOtherCommentsNameThis field is for validation purposes and should be left unchanged.
