You Are @ Step 5 Now!
Step 5 of 5 ( 100% )
In order to properly assess your condition, we must understand how much your neck and/or back problems have affected your ability to manage everyday activities. For each item below, please select each item which most closely describes your condition right now.
Rate Your Pain Intensity
Rate Your Sleeping
Personal Care (washing, dressing, etc.)
Travel (driving, etc.)
Working
Recreation
Frequency of Pain
Lifting
Walking
Standing
Any information that is not provided while filling out this form will need to be reviewed at the clinic on your first visit. By providing this information at this time, your initial appointment intake process will not be so lengthy. Your doctor will need a health history to complete the initial exam.
Additional forms will need to be signed when you arrive at the clinic on your first visit. Please bring a photo ID and any previous care information related to your accident if applicable. Thank you!