Pain Assessment Tool | Non-Surgical Spine Center

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Conditions we Treat
- - Lower Body Pain
  - Lower Back Pain
  - Hip Pain
  - Knee Pain
  - Leg Pain
  - Buttocks Pain
  - Groin Pain
  - Herniated Disc
  - Coccyx/Tailbone Pain
  - Sacroiliac Joint Pain
  - Annular Tears
- - Upper Body Pain
  - Hand Pain
  - Neck Pain
  - Shoulder Pain
  - Elbow Pain
  - Arm Pain
  - Mid Back Pain
  - Herniated Disc
  - Degenerative Disc Disease
  - Failed Back Syndrome
  - Annular Tears
- - Full Body Pain
  - Arthritis
  - Nerve Pain
  - Muscle Pain
  - Bursitis
  - Facet Joint Pain
  - Radiculopathy
  - Diabetic Nerve Pain
  - Peripheral Neuropathy
  - Stenosis
  - Pinched Nerves
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Step 1 of 4

25%

Pain Assessment Tool
STEP ONE: CHECK ALL THAT APPLY*
- Lower Back Pain
- Middle Back Pain
- Neck Pain
- Shoulder Pain
- Arm Pain
- Buttocks Pain
- Leg Pain
- Hip Pain
Other:

Pain Assessment Tool

STEP TWO: WHERE IS YOUR PAIN THE STRONGEST?
Areas of Pain*
STEP THREE: How long have you been experiencing pain?*
- 1-6 Months
- 6-12 Months
- More than a year.

Pain Assessment Tool
STEP FOUR: Have you previously been diagnosed with a condition by a physician?*
- Yes
- No
STEP FIVE: How Would you Like to be contacted?*
- By Phone
- By Email
- No Preference

Pain Assessment Tool

STEP SIX: Contact Information
First Name*
Last Name*
Email:*
Phone:*

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Mt. Pleasant | Goose Creek
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