How did your pain begin? Choose all options that apply.

Accident at home

Vehicle accident

Accident at work/work related

It just began

After surgery

Came on gradually

Sports related

Other

What type of doctors have you seen?

Chiropractor

Pain Management

Neurologist

Orthopaedic Surgeon

General/Family Doctor

Other

None

What is the source of your pain? Choose all the apply

Neck

Back

Knee

Shoulder

Arms

Legs

Headache

Other

Are you experiencing any numbness?

Yes

No

How long have you had the pain?

On a scale of 1 - 10 with 10 being the worst, how would you rate your pain level?

1

2

3

4

5

6

7

8

9

10

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