Date of Birth
Please list any/all allergies:
What is the main problem for which you are seeking treatment?
Was there an event that caused your current pain? (Please be very specific)
Are there factors that make your pain...
Better? (please list)
Worse? (please list)
Please rate your pain intensity on a scale from 0 = no pain to 10 = excruciating, incapacitating worst pain possible.
Your pain at its worst in the past month or since your injury
Your pain at its least in the past month or since your injury
Your current pain
How often do you have your pain?
Constantly (100% of the time)
Nearly constantly (60% to 95% of the time)
Intermittently (30% to 60% of the time)
Occasionally (less than 30% of the time)
Please indicate the location of your pain in the picture below:
Front of Neck
Back of Head
Back of Neck
Bottoms of Feet
Please list all medications and/or supplements you are currently taking:
Practitioner's Phone Number
Do any of the following apply to how your pain feels?
If you selected other, please describe:
Front of Head
Please check all the treatments you have tried or are currently using for your pain:
Spinal Cord Stimulator
Cognitive Behavior Therapy
Trigger Point Injections
Radio Frequency Lesioning
If you selected "other", please describe:
Address (City, State, Zip)
Email Address Text Field Label
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