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Home
About us
Services
Orthopedic Care Services
Pain Management
Spine Care Services
Vascular Care Services
Forms & Evaluations
Contact
Patient Evaluations
Request an Appointment
We Stay With You Every Step of the Way– Call:
844-686-2273
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form
home-form
Step
1
of
6
16%
Pain Location
Where is your primary pain located?
A. Lower back
B. Neck
C. Mid-back
D. Lower back with pain down one leg
E. Neck with pain down one arm
2: Pain Pattern
2. How would you describe your pain?
A. Dull, aching, stiff
B. Sharp or stabbing
C. Burning or electric
D. Tight and sore after activity
E. Deep ache that worsens when standing
3. Does your pain radiate into your arm or leg?
A. No
B. Yes – into one leg
C. Yes – into both legs
D. Yes – into one arm
E. Yes – into both arms
3: Neurological Symptoms
4. Do you experience numbness or tingling?
A. No
B. Yes – down one leg
C. Yes – down both legs
D. Yes – down one arm
E. Yes – down both arms
5. Have you noticed muscle weakness?
A. No
B. Leg feels weak or gives out
C. Foot dragging (foot drop)
D. Weak grip or dropping objects
E. Trouble lifting arm
4: Activity Triggers
6. What makes your pain worse?
A. Bending forward
B. Sitting long periods
C. Standing or walking long periods
D. Leaning backward
E. Lifting or twisting
7. What makes your pain better?
A. Rest
B. Lying down
C. Leaning forward (like over a shopping cart)
D. Changing positions
E. Heat and stretching
5: Duration & Progression
8. How long have you had symptoms?
A. Days to weeks (acute)
B. 1–3 months
C. Over 3 months
D. Years with gradual worsening
9. Has this happened before?
A. No
B. Yes, occasional flare-ups
C. Yes, chronic recurring pain
6: Posture & Structural Signs
10. Do you notice:
A. Uneven shoulders or hips
B. Pain worse when arching backward
C. Leg pain when walking that improves when sitting
D. Pain mostly localized to one small area
E. Pain after heavy lifting
