Gender Male Female Age Range 0-10 11-20 21-30 31-40 41-50 50+ Where does it hurt? Head or Face Neck Shoulders Middle Back Lower Back Chest Arm or Elbow Wrist, Hand or Forearm Abdomen Front of Pelvis Hips or Thighs Knees Shins Ankle or Feet Describe the most painful area When did it start and what makes it better and worse? If there's a second area of complaint, describe it here The reason for treatment is due to a: Work related injury Automobile accident Athletic injury Progressive (no one injury) Unknown Describe any condition that may be related to your pain Describe treatments you have received and medications that you are taking Do you have any of the following (if you don't know what it is, do not check the box): Aortic Aneurysm Spondylolisthesis Moderate to Severe Osteoporosis Pregnancy Lumbar Spinal Fusion or Metal Hardware Spinal or Pelvic Cancer A Recent Low Back Fracture Connective tissue disease like Lupus, Rheumatoid Arthritis or Scleroderma I DON'T BELIEVE I HAVE ANY OF THESE CONDITIONS Please leave your contact information below so that we may accurately respond to your online questionnaire. Name First Name Last Name Email Phone Address City State/Province Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Send Gender Male Female Age Range 0-10 11-20 21-30 31-40 41-50 50+ Where does it hurt? Head or Face Neck Shoulders Middle Back Lower Back Chest Arm or Elbow Wrist, Hand or Forearm Abdomen Front of Pelvis Hips or Thighs Knees Shins Ankle or Feet Describe the most painful area When did it start and what makes it better and worse? If there's a second area of complaint, describe it here The reason for treatment is due to a: Work related injury Automobile accident Athletic injury Progressive (no one injury) Unknown Describe any condition that may be related to your pain Describe treatments you have received and medications that you are taking Do you have any of the following (if you don't know what it is, do not check the box): Aortic Aneurysm Spondylolisthesis Moderate to Severe Osteoporosis Pregnancy Lumbar Spinal Fusion or Metal Hardware Spinal or Pelvic Cancer A Recent Low Back Fracture Connective tissue disease like Lupus, Rheumatoid Arthritis or Scleroderma I DON'T BELIEVE I HAVE ANY OF THESE CONDITIONS Please leave your contact information below so that we may accurately respond to your online questionnaire. Name First Name Last Name Email Phone Address City State/Province Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Federated States of Micronesia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Northern Mariana Islands Ohio Oklahoma Oregon Palau Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip/Postal Send
