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Where is your pain? (choose all that apply)

Arms Buttocks Legs Lower Back Middle Back Neck Shoulders

Where is the pain strongest?

Arms Buttocks Legs Lower Back Middle Back Neck Shoulders

How long have you been experiencing pain?

1 Month or less 1 -6 Months 7 -12 Months 1 Year or more

How would you describe your pain symptoms?

None Sharp Burning Cramping Numbness & Tingling Radiating (throbbing) Shocking (quick jolts of pain

Are you always in pain?

Yes, I am in constant pain that worsens depending on what activity I am doing. No, it comes and goes depending on what activity I'm doing or what position I'm in.

When is your pain at its worst? (choose all that apply)

In the morning after waking up While standing or walking While bending backwards While sitting While lying down While performing strenuous activity

When does your pain feel better?

In the morning after waking up While standing or walking While bending backwards While sitting While lying down While performing strenuous activity

What caused your pain originally?

Not sure Lifting something heavy Vehicle crash Slip or fall Traumatic injury Leaning forward Other

If other please explain:

Have you undergone any of the following?

CT Scan MRI Myelogram Discogram X-Ray Nerve Conduction Study Other None

If other please explain:

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San Antonio, TX 78231

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