Pain Assessment Tool
Let's us know about your pain so we can help you!
Name
*
First Name
Last Name
E-mail
*
Phone Number
*
-
Area Code
Phone Number
Where Do You Have Pain?
*
Lower Back
Middle Back
Neck
Legs
Hip
Shoulder
Arm
Buttocks
Where is Your Pain the Strongest?
Lower Back
Mid Back
Neck
Hip
Legs
Arm
Buttocks
Shoulder
What Number Would you Rate Your Pain today on a scale of 0 (No Pain) to 10 (Severe Pain?)
*
0
1
2
3
4
5
6
7
8
9
10
My Pain is...
*
Sudden
Gradual
Constant
Intermittent
My Pain is Worse at...
*
Morning
Day
Afternoon
Night
Back
Next
Please select ALL of the Previous Treatment You have received for this problem.
*
Physical Therapy
Massage
Home exercise
Chiropractor
Acupuncture
Brace
Epidural steroid
Facet injection
Trigger point
Other
Because of my pain, I am unable to...
*
Type answer in space provided.
Do you feel numbness or tingling?
*
Yes
No
Do you have a curve or mass near your spine?
*
Yes
No
Are you experiencing difficulty walking or increase falls?
*
Yes
No
Are you experiencing bladder or bowel incontinence or retention?
*
Yes
No
Please select all that describe your pain.
*
Burning
Shooting
Sharp stabbing
Tingling
Cramping
Aching
Throbbing
Pulling/tearing
Other
Does your pain radiate?
*
Yes
No
Back
Next
Please indicate if you have had any of the following tests in the last year for your problem.
*
X-Ray
MRI
CT Scan
EMG/NCS
None of the above
Other
Have you had surgery for this problem?
*
Yes
No
Please list any medications used to treat your pain/problem.
*
Is there anything else you would like Dr. Nemeth to know?
*
May we contact you via phone or email to discuss your treatment options?
*
Yes
No
Submit
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