Begin to find answers just by answering some basic questions.

Based on your results, you'll have the option to connect with a doctor who can help identify the source of your pain and start you on a customized treatment plan.

11

HOW OLD ARE YOU?

I AM:

WHERE IS YOUR PAIN LOCATED?

On the Diagram, Select the Areas Where You Feel Pain.

FRONT BACK

Rate Your Pain by Selecting One Number That Best Describes Your Pain on Average.

1 being the least painful while 10 being the most.
Slide dial to rate your pain

Does Your Pain Typically Fluctuate or Remain Constant Throughout the Day?

During the Past 24 Hours, Pain Has Interfered with Your:

Select all that apply.

Which Statement Below Best Describes the Pain You Are Experiencing?

How Long Have You Been Suffering From Pain?

I Believe My Pain is Due to:

Select all that apply.

What Kinds of Things Make Your Pain Feel Better?

Select all that apply.

MEDICATIONS


SELF MANAGEMENT
CLINICAL OUTPATIENT SERVICES


PHYSICAL ACTIVITY
STRESS REDUCTION


OTHER

What Kinds of Things Have Made Your Pain Feel Worse or Have Failed to Alleviate Pain if You Have Already Tried Them?

Including all treatments or medications.

MEDICATIONS


SELF MANAGEMENT
CLINICAL OUTPATIENT SERVICES


PHYSICAL ACTIVITY
STRESS


OTHER
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