Pain Quiz | Pain & Spine Specialists Maryland and Pennsylvania

1

What Hurts? (Multiple Selections Allowed) * This field is required.

Back Pain

Neck Pain

Abdominal / Pelvic Pain

Knee Pain

Shoulder Pain

Hip Pain

Headaches / Migraines

Sciatica Pain

Bulging / Herniated Disc

Neuropathy / Neuralgia (Nerve Pain)

2

How long have you had your current pain problem?* This field is required.

A few Weeks

Several Months

About A Year

Many Years

My Whole Life

3

Severity of Pain* This field is required.

Mild

Moderate

Moderate-Severe

Severe

4

Frequency of Pain* This field is required.

Constantly (100% of the time)

Intermittently (30 to 60% of the time)

Nearly Constantly (60 to 95% of the time)

Occasionally (less than 30% of the time)

6

Does Your Pain Limit Your Ability To Walk?* This field is required.

Yes

No

7

How Long Can You Sit?* This field is required.

None

30 Minutes - 1 Hour

1 - 2 Hours

Other

8

How Long Can You Stand?* This field is required.

None

30 Minutes - 1 Hour

1 - 2 Hours

9

Please Provide Your Email* This field is required.We will send you an email with additional resources after completing this quiz

10

Select A StateThis selection will make sure the resources we send are specific to providers and treatments offered at locations near you.

Maryland

Pennsylvania

Florida

Virginia

Ohio

11

Would You Like To Provide Any More Details? (Optional)Any more details that you would like to share, that were not asked in previous questions.

12

Send Name

13

Admin Email

example@example.com

14

Pain Concern list