1 Identify Your Pain

2 Your Condition

3 Recent Treatments

4 Treatment Effectiveness

5 Your Results

Step 1: Tell us about your pain

Show us where it hurts. Choose all that apply:
Body Pain

Lower Back

Middle Back

Neck

Shoulders

Arms

Buttocks

Legs

Where is the pain strongest?
How long have you been experiencing pain?
Have you been diagnosed with a specific condition?

Step 2: Describe your pain for us

How would your describe your pain?
Are you always in pain?
Do you have any of the following symptoms?

Step 3: Tell us more about your symptoms

When is your pain at its worst? Choose all that apply.
When does your pain feel better?
What caused your pain originally?
If other, please explain:

Step 4: Tell us about your past treatment

Have you undergone any of the following?
If other, please explain:

Step 2: Tell us about your condition

What condition do you have?

Step 3: Tell us about any recent treatments

Have you undergone any of the following?
If other, please explain:
How long ago was your last Ct Scan, MRI, X Ray, or Nerve Condition Study?
Are you currently undergoing any treatment?
If yes, which treatments?
If other, please explain:

Step 4: Tell us about the effectiveness of your treatments

How effective is your current treatment?
What other treatments have you undergone?
If other, please explain:

Step 5: Get your results

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