| Name |
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| Email |
|
| Is this your first episode of back pain? |
|
| Is this due to an injury? |
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| How long have you had your pain? |
|
| Is your pain getting better or worse? |
|
| How bad is your pain? |
|
| Do you have pain/numbness down your arm or leg? |
|
| Do you have numbness in your buttocks or genital region, or difficulty going to the bathroom? |
|
| What have you already tried? |
|
DC - Did it help? |
|
|
LMP - Did it help? |
|
|
PT - Did it help? |
|
|
OTC Meds - Did it help? |
|
|
Prescription Meds - Did it help? |
|
|
|
