Virtual Therapy
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Virtual Therapy
How It Works
My Account
Contact
Text Us
Email Us
Call Us
MODERATE BACK AND LEG PAIN SURVEY
Thank you for your answers. Based on your responses, we are able to help treat your back and leg pain! Please complete the following questionnaire so we can recommend the best treatment plan for you.
Please answer the following questions:
When does your back and leg pain hurt the worst?
When I sit
When I get up from sitting
When I walk
Equal amounts of the above
Other
When I get up and move around, it feels…
Better and better.
Worse and worse.
This has no effect on it.
Which chair is the worst?
Straight-backed, hard chair
Soft couch, no support
It doesn’t matter
Is it worse at the beginning of the walk and then as you walk, it gets better and better?
Yes
No
What side is your pain on?
Right
Left
Does it "pop", "click" or "hitch" in the same spot every time you get up?
Yes
No
Does it feel worse and worse the more you walk?
Yes
No
Sit up really tall right now until a strain is felt across your low back for at least 3 minutes. Arch your back. Does that feel…
Better
Worse
What side is your pain on?
Right
Left
Center
I’m Here For…
Back Pain
Back Pain
You are experiencing pain or discomfort in your upper- or lower-back regions.
Continue >
Neck Pain
Neck Pain
You are experiencing pain or discomfort in your neck region.
Continue >
Leg Pain
Leg Pain
You are experiencing shooting pains, numbness, or discomfort in one or both of your legs.
Continue >
Severe Injury
Severe Injury
You have sustained a physical injury or fall that has resulted in blood loss, possible fracture, or severe pain.
Continue >
