Tell Us About Your Pain

Is chronic neck and back pain preventing you from leading the active lifestyle that you want? Use our Pain Tool to evaluate your symptoms & get back to living!

Where does it hurt?

Choose all that apply:

Lower Back

Middle Back

Neck

Shoulders

Arms

Buttocks

Knee

Legs

?

Other

Where is the pain strongest?

Lower Back

Middle Back

Neck

Shoulders

How long have you been experiencing pain?Select one...1 month or less1-6 months7-12 months1 year or moreHow would you describe your pain?

Sharp
‍

Burning
‍

Cramping
‍

Throbbing
‍

Quick Jolts of Pain

Is the injury work related?Select one...YesNoIs the injury automobile accident related?Select one...YesNoHave you recently had any of the following?

Choose all that apply:

CT Scan
‍

MRI
‍

X-Ray
‍

Nerve Conduction Study

?

Other
(Please explain)

--

None

Other ExplanationWhat's your insurance plan?

Aetna

Cleveland Clinic

Medical Mutual

UnitedHealthcare

Blue Cross Blue Shield

Humana
‍

Medicare | Railroad Medicare

Workers Compensation

Cigna
‍

Medicaid Products

ML Healthcare

Other

If other, please tell us about your insurance plan:
Personal Information

First Name*Last Name*

Email*

Primary Phone*Secondary Phone

Best Time to Call*Select one...MorningMiddayAfternoonInterested in Telehealth?Select one...YesNoComments

CAPTCHA

Thank you! Your submission has been received!

Oops! Something went wrong while submitting the form.