Tell us about your pain Download our Patient Intake Form or fill out below… Company First name * Last name * Email Address * A few quick questions about your body... We respect your privacy and will never share any of your personal information to anyone, ever. Where does it hurt? Head Neck Upper Back Mid-Back Lower Back Other, please explain... How often do you feel it? Constantly = 100% of the day Frequently = 75% of the day Occasionally = 50% of the day or less How bad does it hurt on a 1 to 10 scale (1 = no pain; 10 = on the ground, fetal position, writhing in pain, and crying uncontrollably) 1 2 3 4 5 6 7 8 9 10 Can you describe the quality of symptoms? dull achy, sharp stabby, burning, shooting electrical, throbbing, other Do you have any radiating/shooting symptoms into your extremities? right arm, left arm, right leg, left leg, other What makes it feel better? Hot water/shower, ice, stretching, ibuprofen(Advil, Motrin), acetaminophen (Tylenol), rest, massage, NOTHING, other What provokes it or makes it increase in severity? Bending, twisting, lifting, stooping, sitting, standing, laying flat on back, other
