[DEV] Advance Pain Institute of Texas

1

What is your gender?* This field is required.

Male

Female

2

Where does the pain hurt the MOST?* This field is required.

Lower back / lumbar region

Buttock / posterior hip

Groin

Leg / thigh

Other

3

Do you avoid sitting for long periods of time because of the pain?* This field is required.

Yes

No

4

Does climbing stairs make the pain worse?* This field is required.

Yes

No

5

Does traveling in a vehicle make your back or buttocks pain worse?* This field is required.

Yes

No

6

Is it painful to stand on one leg (affected side) for a prolonged period?* This field is required.

Yes

No

7

Does getting in and out of a car worsen the pain?* This field is required.

Yes

No

8

Your answers indicate the SI joint could be the source of your pain.

9

Your responses do not indicate whether the SI joint is causing your lower back pain. We recommend scheduling an appointment with your doctor to discuss your symptoms

10

Please fill out the form below for a priority appointment.

11

Name

First Name

Last Name

12

Phone Number

Please enter a valid phone number.