Chronic Pain Quiz

Gender *

Male

Female

Are you in pain for more than 10% of your day? *

Yes

No

Where is your pain? (Select all that apply) *

Neck / Upper Back

Arms

Shoulders

Low Back

Hips

Legs

Knees

Ankle

Feet

Other

Describe your pain? (Select all that apply) *

Burning

Dull Ache

Numbness

Sharp

Shooting

Stabbing

Tingling

Throbbing

Other

How long have you been in pain? *

Less than 6 months

6 months - 5 years

More than 5 years

Does the pain interfere with your sleep? *

Yes

No

Do you make decision in your life based on your level of pain? *

Yes

No

Name *

First Name

Last Name

Phone *

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