Patient Pain Quiz Patient Pain Quiz "*" indicates required fields Step 1 of 5 20% Where are you experiencing the most pain?* Neck or Upper Back Middle Back Lower Back Where are you experiencing the most pain, tenderness or tightness?* Neck or Upper Back Hands or Arms Lower Back Hips or Tailbone Feet or Legs Have you been diagnosed with any of the following conditions?* Facet Joint Pain Failed Back Syndrome Herniated Disc Sacroiliac Joint Pain Sciatica Spinal Deformity Spinal Injury Spinal Stenosis Spondylolisthesis Spondylosis Not Sure No Are you currently undergoing any of the following treatments for your pain?* Alternative therapy Back braces Electrical nerve stimulation Exercise Injections Pain medications Spinal realignment Other None Please explain...How effective is your current treatment?Choose an option below...Provides effective relief, but I'm interested in trying something newProvides moderately effective relief, but my pain reappears in a few weeksProvides temporary relief, but my pain reappears in a few hours or daysDoes not provide me with any relief or makes my pain worseI do not currently have a treatment plan to address my painHave you tried any of the following treatments? Acupuncture Anti-inflammatory medications Chiropractic care Epidural steroid injections Massage/Ultrasound Narcotic medications Orthotics Traction TENS units Trigger point injections Other No Please explain...How effective were your previous treatments?Choose an option below...Moderately effective, but my pain never fully disappearedProvided temporary relief, but my discomfort returnedDid not affect my pain level or conditionI do not have a previous treatment plan Which of the following age ranges best describes you? I am a child age 10 or younger I am a pediatric patient between the ages of 11 and 18 I am a young adult between the ages of 19 and 30 I am an adult between the ages of 31 and 50 I am an adult between the pages of 51 and 65 I am older than 65 years of age Do you, or anyone in your immediate family, suffer from any heart conditions?* Yes No Other Would you consider yourself healthy enough for surgery* Yes No Other Can you describe any other current treatments not listed above? Have you had any of the following medical exams or tests?* Blood sample CT scan or X-Ray Diagnostic injections MRI Nerve conduction study Range of motion or reflex test Physical examination Other None Please explain...How recent were your medical exams or tests taken?Choose an option below...Less than 2 weeks2 weeks to 1 month1 month to 6 months6 months to 1 year1 year or longerCan you describe any other medical exams not listed above? Name First Last PhoneEmail Would you like to receieve additional information about our latest minimally invasive procedures?* Yes No Additional Comments or QuestionsCAPTCHACommentsThis field is for validation purposes and should be left unchanged.
