Patient Pain Quiz

• Step 1 of 9

  Where are you experiencing the most pain?*

  • Neck
  • Arms
  • Middle Back
  • Lower Back
  • Legs

• Step 2 of 9

  Have you been diagnosed with any of the following conditions?*

  • Facet Joint Pain
  • Cervical Radiculopathy
  • Lumbar Radiculopathy
  • Herniated Disc
  • Sacroiliac Joint Pain
  • Sciatica
  • Spinal Deformity
  • Spinal Stenosis
  • Spondylolisthesis
  • Spondylosis
  • Not Sure
  • No

• Step 3 of 9

  Are you currently undergoing any of the following treatments for your pain?*

  • Alternative therapies
  • Back/Neck braces
  • Chiropractics
  • Injections
  • Pain medications
  • Physical Therapy
  • Other
  • None

• Step 4 of 9

  Have you tried any of the following treatments?*

  • Acupuncture
  • Anti-inflammatory medications
  • Chiropractic care
  • Epidural steroid injections
  • Massage/Ultrasound
  • Narcotic medications
  • Orthotics/Braces
  • Radiofrequency Ablation
  • Spine Surgery
  • Traction
  • TENS units
  • Trigger point injections
  • Other
  • No
  Can you describe any other current treatments not listed above?

• Step 5 of 9

  How effective were your previous treatments?*

  • Significant improvement
  • Moderately effective, but my pain never fully disappeared
  • Provided temporary relief, but my discomfort returned
  • Did not effect my pain level or condition
  • I do not have a previous treatment plan

• Step 6 of 9

  Which of the following age ranges best describes you?*

  • My child is 10 years of age or younger
  • My child is between the ages of 11 and 18
  • I am a young adult between the ages of 19 and 30
  • I am an adult between the ages of 31 and 50
  • I am an adult between the ages of 51 and 65
  • I am an adult between the ages of 65 and 85
  • I am adult older than 85 years old

• Step 7 of 9

  Have you had any of the following medical exams or tests?*

  • CT scan
  • MRI
  • Nerve conduction study
  • X-ray
  • Other
  • None
  Can you describe any other medical exams not listed above?

• Step 8 of 9

  How recent were your medical exams or tests taken?*

  • Within the last 4 weeks
  • 1 month to 6 months
  • 6 months to 1 year
  • 1 year or longer

• Step 9 of 9

  First Name*
  Last Name*
  Phone*
  Email*
  Questions or Comments?*
  *

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