Pain Evaluation

How old are you?

Where is your pain?

•  Lumbar (Lower Back)
•  Thoracic (Mid Back)
•  Cervical (Neck)

How would you describe your pain?

•  Knife Cutting
•  Sharp
•  Burning
•  Cramping
•  Throbbing
•  Other

Where is the pain worst?

Neck Upper Back Middle Back Lower Back Right Arm Left Arm Both Arms Right Leg Left Leg Both Legs Other

How long have you been experiencing this pain?

Days Weeks Months Years

How did your pain start?

Work Related Motor Vehicle Accident Personal Injury Other

Do you have any associated symptoms?

•  Pins
•  Needles
•  Numbness
•  Weakness
•  Tingling
•  Other

What triggers your pain?

•  Sitting
•  Standing
•  Walking
•  Laying Down
•  Bending Forward
•  Bending Backward
•  Other

What improves or alleviates your pain?

•  Sitting
•  Standing
•  Walking
•  Laying Down
•  Bending Forward
•  Bending Backward
•  Other

What tests have you had?

•  CT Scan
•  MRI
•  XRay
•  Other

What treatments have you had to treat the pain?

•  Chiropractic Treatment
•  Physical Therapy
•  Acupuncture
•  Spinal Injections
•  Open Spine Decompression
•  Fusion
•  Other

Personal Information

Name

First name *

Last name *

Location

State * Select State Not Applicable Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming

Phone

Home Phone *

Email

Email *

Other

Best time anytime 9am - 12pm 12pm - 3pm 3pm - 6pm 6pm - 9pm

Insurance * Select Insurance Private Medicare Medicare +Supp None LOP Work Comp Self Pay

•  HMO
•  PPO
•  POS
•  Other

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