- On a scale of 1-10, how would you rate your back pain?
(1=mild, 10=severe) - 1-3
- 4-6
- 7-9
- 10
- 11
- How often do you experience back pain?
- Occasionally
- Daily
- Multiple times a day
- Only during certain activities
- When did you first notice your back pain?
- within last 2 weeks
- over 2 months ago
- it’s been so long I can’t remember
- What part of your back is affected?
- Lower back
- Mid back
- Upper back
- Across the entire back
- Does the pain radiate to other areas?
- Yes
- No
- Are there specific activities that trigger the pain?
- Sitting
- Lifting
- Bending
- Standing
- Sleeping
- Does either of these options help relieve your back pain?
- rest
- ice
- heat
- medication
- chiropractic care
- What is your age?
- 1-10
- 11-16
- 17-25
- 26-35
- 35-45
- 46-60
- 60-75
- 75+
- Your normal physical activity level:
- Sedentary
- Moderately Active
- Very Active
- Is this injury from one of the following?
- Auto Accident
- Work Related Injury
- Slip or Fall
- Other
- Not Sure
- Are you or could you be in the Austin area for treatment?
- Yes, I am in the Austin TX area.
- Yes, I can travel to Austin TX for diagnosis and/or treatment.
- No, I cannot be in Austin for treatment (but I am in the USA).
- No, I am outside of the USA