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Neck Pain

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Your Name*

First Last

Average pain level with activity?*

1-3: Mild pain, easily manageable, may be a minor discomfort, no need to take over the counter medication.
4-6: Moderate pain, noticeable and may interfere with daily activities, relief with over the counter medication.
7-9: Severe pain, difficult to tolerate, significantly impacts daily functioning, little to no relief with over the counter medication.
10/10: intolerable, extreme, “I need to go to the hospital”.

0 - No Pain

1 - Mild

2 - Mild

3 - Mild

4 - Moderate

5 - Moderate

6 - Moderate

7 - Severe

8 - Severe

9 - Severe

10 - Extreme

Is your pain the result of a traumatic injury?*

Yes

Type of Injury?*

A Fall

A Motor Vehicle Accident

Direct Blow

Other

Have you seen a medical provider for this problem?*

Yes

Have you seen a medical provider for this injury?*

Yes

How long have you had these symptoms?*

Less than 1 month

1 to 3 months

3 to 6 months

More than 6 months

Are you able to get any form of pain relief (not necessarily elimination of pain) with position changes or movements, ex. sitting, standing, laying on back, etc.?*

Yes

Any recent changes in vision, smell, taste, or hearing associated with your neck pain?*

Yes

Do you have headaches?*

Yes

Are the headaches on one side or both sides?*

One Side

Both Sides

Do you have radiating pain or numbness/tingling in arm(s)?*

Yes

Your radiating symptoms, are they in one or both arms?*

One Arm

Both Arms

Do you have significant weakness in arm(s) associated with neck pain?*

Yes

Read Important Information Below*

Based on your answers to the previous questions, we recommend making an appointment with your primary care provider to rule out significant pathology that may require further intervention. If you would like to start one of our rehabilitation plans in the mean time, click below to see the one we recommend for you.

I have read and understand the recommendation being made

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