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! Tell Us About Your Pain 1 2 3 4 5 Pain Assessment ProgressWhere 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:*1 month or Less1-6 months7-12 months1 year or more Pain Assessment ProgressHow would you describe your pain? Sharp Burning Cramping Throbbing Quick Jolts of Pain Is the injury work related?*YesNoIs the injury automobile accident related?*YesNo Pain Assessment ProgressHave you undergone any of the following?Choose all that apply: CT Scan MRI X-Ray Nerve Conduction Study Other (Please Explain) None Other Explanation Pain Assessment ProgressWhat’s your insurance plan?* Aetna Cleveland Clinic EPH Tier 1 Medical Mutual United Health Care Bluecross Humana Medicare Workers Compensation Cigna Medicaid Products ML Healthcare Other If other, please tell us about your insurance plan: Personal informationFirst Name**Last Name**Email** Primary Phone**Secondary PhoneBest Time to Call:**MorningMiddayAfternoonInterested In Telehealth?YesNoCommentsCommentsThis field is for validation purposes and should be left unchanged.