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Our Providers
Resources
Pain Assessment
Treatment Finder
Patient Portal
Menu
Our Providers
Resources
Pain Assessment
Treatment Finder
Patient Portal
Pain Assessment
Fill out the pain assessment form below to take the first step toward recovery.
Where is your pain located?
Knee
Shoulder
Hip
Foot & Ankle
Hand, Wrist & Elbow
How long have you experienced this pain?
1 month or less
1 - 6 months
7 - 12 months
1 year or more
How would you describe this pain?
Sharp
Burning
Cramping
Numbness or tingling
Radiating or throbbing
Shocking (quick jolts of pain)
Are you always in pain?
Yes, I'm in constant pain that may worsen depending on the activity I'm doing.
No, it comes and goes depending on what activity I'm doing or what position I'm in.
What caused your pain or injury originally?
Car accident
Slip or fall
Traumatic Injury
Not sure
Overuse and repetitive movements
Other
Have you been diagnosed with a specific condition?
Yes, I've been diagnosed by a physician.
No, I have not been diagnosed by a physician.
Have you undergone any of the following diagnostic studies?
CT Scan
MRI
X-Ray
EMG Test
Nerve Conduction Study
Other
None of the above
First Name
Last Name
Email
Phone
Insurance Type
Insurance Type
PPO
HMO
Worker's Comp
Medicare
Medicaid
Self-Pay
Questions or Comments
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