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Pain Assessment

Take our Pain Assessment to determine what your next steps are for relief. Here is our form that will lead you through a series of back and neck pain assessment questions. Check all the boxes that apply to your condition.

After the Pain Assessment, you will get an email confirmation and further information to give you the next step to recovery. If you have any questions feel free to call 770-460-1911 or contact us.

Self Assessment for Back Pain

Please note that all fields followed by an asterisk must be filled in.

First Name*
First Name*

E-mail Address*
E-mail Address*

Zip/Postal Code*
Zip/Postal Code*

Home Phone*
Home Phone*

Pain Intensity*
Pain Intensity*

	I have no pain at the moment
	The pain is very mild at the moment
	The pain is moderate at the moment
	The pain is fairly severe at the moment
	The pain is very severe at the moment
	The pain is the worst imaginable at the moment

Personal Care (eg. washing, dressing)*
Personal Care (eg. washing, dressing)*

	I can look after myself normally without causing extra pain
	I can look after myself normally but it causes extra pain
	It is painful to look after myself and I am slow and careful
	I need some help but can manage most of my personal care
	I need help every day in most aspects of self-care

Lifting*
Lifting*

	I can lift heavy weights without extra pain
	I can lift heavy weights but it gives me extra pain
	Pain prevents me lifting heavy weights off the floor but I can manage if they are conveniently placed eg. on a table
	Pain prevents me lifting heavy weights but I can manage light to medium weights if they are conveniently positioned
	I can only lift very light weights
	I cannot lift or carry anything

Walking*
Walking*

	Pain does not prevent me walking any distance
	Pain prevents me from walking more than 2 kilometers
	Pain prevents me from walking more than 1 kilometer
	Pain prevents me from walking more than 500 meters
	I can only walk using a stick or crutches
	I am in bed most of the time

Sitting*
Sitting*

	I can sit in any chair as long as I like
	I can only sit in my favourite chair as long as I like
	Pain prevents me sitting more than one hour
	Pain prevents me from sitting more than 30 minutes
	Pain prevents me from sitting more than 10 minutes
	Pain prevents me from sitting at all

Standing*
Standing*

	I can stand as long as I want without extra pain
	I can stand as long as I want but it gives me extra pain
	Pain prevents me from standing for more than 1 hour
	Pain prevents me from standing for more than 30 minutes
	Pain prevents me from standing for more than 10 minutes
	Pain prevents me from standing at all

Sleeping*
Sleeping*

	My sleep is never disturbed by pain
	My sleep is occasionally disturbed by pain
	Because of pain I have less than 6 hours sleep
	Because of pain I have less than 4 hours sleep
	Because of pain I have less than 2 hours sleep
	Pain prevents me from sleeping at all

Sex Life (if applicable)

	My sex life is normal and causes no extra pain
	My sex life is normal but causes some extra pain
	My sex life is nearly normal but is very painful
	My sex life is severely restricted by pain
	My sex life is nearly absent because of pain
	Pain prevents any sex life at all

Social Life*
Social Life*

	My social life is normal and gives me no extra pain
	My social life is normal but increases the degree of pain
	Pain has no significant effect on my social life apart from limiting my more energetic interests e.g. sport
	Pain has restricted my social life and I do not go out as often
	Pain has restricted my social life to my home
	I have no social life because of pain

Traveling*
Traveling*

	I can travel anywhere without pain
	I can travel anywhere but it gives me extra pain
	Pain is bad but I manage journeys over two hours
	Pain restricts me to journeys of less than one hour
	Pain restricts me to short necessary journeys under 30 minutes
	Pain prevents me from traveling except to receive treatment

Symptoms*
Symptoms*

	Numbness and Tingling
	Pain upon coughing or sneezing
	Pain upon bowel movements

List any Additional Information

What do you think is the cause?

Please enter the word that you see below.

Submit your Pain Assessment and the next page will confirm your participation.

Success Stories

Nurse Avoids Back Surgery

idd patient, back pain, grady trauma nurse

Grady Trauma Nurse Dennis Guice says "After half of my treatments, I can tie my shoes again. I have more range of motion and I haven't missed any work."

No Risk with Back Surgery Alternative for 92 Year Old

Juanita Ridenhour was not going to let 3 degenerated discs interrupt her active lifestyle with cleaning and yardwork. Now after IDD Therapy® she says "I'm back now to doing everything at home."

No More Pain in the Neck

Web developer Kelly Nichols says, "IDD has made me feel stronger and I'm not afraid to move my neck. I think that used to cause my spasms. IDD worked for me."

Get Your Life Back

Dr. John Thomas, D.C. has helped thousands of patients get fast and effective relief from sports and personal injuries without the use of drugs or surgery. His clinic specializes in IDD Therapy® and sports injury.

Resources

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Conditions

Back Pain Neck Pain Sciatica Herniated Disc Degenerative Disc Disease Osteoarthritis Facet Syndrome Spinal Stenosis

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Allied Healthcare Clinics
770-460-1911
170 Bastille Way, Suite A
Fayetteville, GA 30214 Contact Us
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The information on Proven-Back-Pain-Relief.com is intended for general knowledge and not to be substituted for medical or chiropractic advice, diagnosis or treatment of a specific condition.
For all health issues seek professional chiropractic or medical assistance.