Registration Form

Pain Assessment Tool

Let's us know about your pain so we can help you!
Name*

First NameLast Name
E-mail*
Phone Number*

Area CodePhone Number
Where Do You Have Pain?*

Lower BackMiddle BackNeckLegsHipShoulderArmButtocks
Where is Your Pain the Strongest?
What Number Would you Rate Your Pain today on a scale of 0 (No Pain) to 10 (Severe Pain?)*

012345678910
My Pain is...*
My Pain is Worse at...*

Please select ALL of the Previous Treatment You have received for this problem.*

Physical TherapyMassageHome exerciseChiropractorAcupunctureBraceEpidural steroidFacet injectionTrigger pointOther
Because of my pain, I am unable to...*
Type answer in space provided.
Do you feel numbness or tingling?*

YesNo
Do you have a curve or mass near your spine?*

YesNo
Are you experiencing difficulty walking or increase falls?*

YesNo
Are you experiencing bladder or bowel incontinence or retention?*

YesNo
Please select all that describe your pain.*

BurningShootingSharp stabbingTinglingCrampingAchingThrobbingPulling/tearingOther
Does your pain radiate?*

YesNo

Please indicate if you have had any of the following tests in the last year for your problem.*

X-RayMRICT ScanEMG/NCSNone of the aboveOther
Have you had surgery for this problem?*

YesNo
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?*

YesNo
Should be Empty: