Pain Assessment Tool

STEP 1:

Tell Us About Your Pain and Symptoms

Neck

Spine

Hip

Ankle & Foot

Hands & Wrist

Elbow

Back

Knee

Where is the pain strongest?

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

CONTINUE TO STEP 2

STEP 2:

Describe Your Pain For Us

None
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.

BACK CONTINUE TO STEP 3

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

BACK CONTINUE TO STEP 4

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

BACK CONTINUE TO STEP 5

STEP 5:

Get Your Results

*All fields are required

*

First Last

*

Date Of Birth*

MM

DD

YYYY

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