Pain Assessment Where does it hurt?* Neck Shoulders Elbow Back Wrist Hip Knee Ankle How long have you been experiencing the pain?*1 Month or less2-6 months7-12 months1 year or more How would you describe your pain?* Sharp Burning Cramping Throbbing Quick Jolts Of Pain Are you always in pain?*Yes, I am in constant pain that worsens depending on the activity I’m doingNo, it comes and goes depending on the activity I’m doing Do you have any of the following symptoms? Pins and needles Numbness Tingling sensations Progressing weakness Loss of coordination None Have you ever undergone any of the following:* CT Scan MRI X-RAY NERVE CONDUCTION STUDY OTHER NONE What’s your insurance plan?* BCBS FEP BlueCross BlueShield Anthem Aetna Medicare Cigna United Health Care TriCare Geha MHBP Kaiser Samba Please fillout the form to get your resultsName*Email* Phone*EmailThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.