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Condition Check
Where is your pain? (choose all that apply)
Lower Back
Middle Back
Neck
Shoulders
Arms
Buttocks
Legs
Where is the pain strongest?
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Lower Back
Middle Back
Neck
Shoulders
Arms
Buttocks
Legs
How long have you been experiencing pain?
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A month or less
One to six months
Seven months to a year
A year or more
How would you describe your pain?
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Sharp
Burning
Cramping
Radiating (throbbing)
Shocking (quick jolts of pain, with minor pain in-between
Are you always in pain?
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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 am doing.
Do you have any of the following symptoms? (choose all that apply)
Pins and needles feeling
Numbness
Progressing weakness
Tingling sensations
Loss of coordination
When is your pain at its worst? (choose the one that most applies)
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In the morning after waking up
While standing or walking
While sitting
While performing strenuous activity
When does your pain feel better?
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Sitting down
Standing up
Walking
Lying down and relaxing
Leaning forward
Bending backward
What caused your pain originally?
Click on the arrow to choose
Lifting something heavy
Vehicle crash
Slip or fall
Traumatic injury
Leaning forward
Other
Have you undergone any of the following tests?
Click on the arrow to choose
CT Scan
MRI
X-Ray
Nerve conduction study
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