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Port Richmond, PA Office
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CONDITION CHECKER
Is chronic neck and back pain preventing you from leading the active lifestyle that you want? Use our Condition Checker to evaluate your symptoms & get back to life!
Step 1 Group
Step 1: Tell Us About Your Pain
Where are you experiencing pain? (Choose all that apply)
*
Cervical (neck) region
Thoracic (mid-spine) region
Lumbar (lower back) region
Shoulders or Arms
Hip, Buttocks, or Legs
Joints (wrists, elbows, knees, ankles, etc.)
Other
Where is your pain the most severe?
Selection an option below
Cervical (neck) region
Thoracic (mid-spine) region
Lumbar (lower back) region
Shoulders or Arms
Hip, Buttocks, or Legs
Joints (wrists, elbows, knees, ankles, etc.)
How long have you been experiencing pain?
0 to 6 months
6 months to 1 year
1 to 2 years
2 years or more
Step 2 Group
Step 2: Tell Us About Your Symptoms
Describe any pain-related symptoms. (Choose all that apply)
*
Stabbing, shooting, or radiating pain
Tenderness, throbbing, or dull aching
Numbness, tingling, or pins-and-needles sensations
Burning or stinging
Stiffness or reduced range of motion
Localized swelling or global inflammation
Muscular cramps or spasms
Progressive weakness
Lack of balance or coordination
Difficulty walking, bending, sitting, or rotating the spine
Abnormal curvature of the spine
"Crunching" or grinding sensations in joints
Other
Step 2.1 Group
Step 2.1: We Need A Little More Information
Where are you experiencing stabbing, shooting, or radiating pain?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
How intense is the stabbing, shooting or radiating pain?
0
1
2
3
4
5
Where are you experiencing tenderness, throbbing or dull aching?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
How severe is the tenderness, throbbing or dull aching?
0
1
2
3
4
5
Where are you experiencing numbness, tingling, or pins-and-needles sensations?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
Is the numbness, tingling or pins-and-needles sensation constant?
Yes
No
Comes and goes
How intense is the numbness, tingling, or pins-and-needles sensations?
0
1
2
3
4
5
Where are you experiencing burning or stinging?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
Is the burning or stinging constant?
Yes
No
Comes and goes
How severe is the burning or stinging?
0
1
2
3
4
5
Where are you experiencing stiffness?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
Where are you experiencing reduced range of motion?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
Where are you experiencing swelling or inflammation?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
How severe is the swelling or inflammation?
0
1
2
3
4
5
Where are you experiencing muscular cramps or spasms?
Neck
Shoulders
Arms
Hands
Lower Back
Hips
Buttocks
Legs
Feet
Do the cramps or spasms limit your ability to walk or move freely?
Yes
No
Sometimes
Where are you experiencing progressive weakness?
Upper Extremities – Arms or Hands
Lower Extremities – Legs or Feet
Step 3 Group
Step 3: Tell Us About Your Pain History
Which circumstance resulted in your pain?
*
Select an option below
Abnormal birth-related condition
Accident or traumatic injury
Aging or normal wear and tear
Failed neck or back surgery
Other
If other, please specify.
Have you undergone any of the following tests?
*
CT Scan
MRI
X-Ray
EMG or Nerve Conduction Study
Other
Have you tried any of the following treatments?
Self-care (rest, over-the-counter medications, ice & heat application, etc.)
Alternative Therapy (Acupuncture, Yoga, Massage Therapy, etc.)
Chiropractic Care
Physical Therapy
Pain Management (prescription strength pain medication, cortisone injections, etc.)
Surgical Intervention
None
Other
If other, please specify.
What type of insurance do you have?
*
Preferred Provider Organization (PPO)
Exclusive Provider Organization (EPO)
Health Maintenance Organization (HMO)
Personal Injury Protection (PIP)
Worker's Compensation
Medicare
Medicaid
Self Pay
Other or Unknown
Step 4 Group
Step 4: Get My Condition Results
First Name
*
Last Name
*
Email
*
Phone Number
*
Best Time to Contact You
As soon as possible
Morning
Afternoon
Evening
Additional Comments or Questions?
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LETS GET IN
CONTACT
First Name
*
Last Name
*
Email
*
Phone
*
Message
Best Time To Call
Best Time To Call
As Soon As Possible
Morning
Afternoon
Evening
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