Please check all that applies to you:

    What are your chief complaints?
    Neck PainLow Back PainButtocks PainHip PainLeg PainShoulder PainArm Pain

    How long have you had this problem?
    Less than a month1 - 6 months6 months - 1 yearMore than 1 year

    Since the problem began, has it gotten worse?
    YesNo

    How would you describe your pain?
    DullSharpBurningTinglingShootingNumbnessThrobbing

    Has your pain affected your life in a negative way?
    YesNo If yes, please describe below.

    Has it affected your Work?
    YesNo If yes, please describe below.

    Do you have a MRI or X-Rays?
    YesNo

    What activities aggravate your condition?
    WalkingStandingBendingLiftingLying down

    What activities relieves your pain?
    WalkingStandingBendingLiftingLying down

    If you are interested in correcting your problem, eliminating your pain and increasing your energy levels, please submit the survey and we will contact you.

    Best time to call?
    MorningAfternoonEveningAnytime

    Your Name

    Your Phone