Neck and Back Pain Self Test

Are You Tired of Neck or Back Pain?
Are You Looking For Help?

This questionnaire has been designed to give the Chiropractor information as to how your neck or back pain has affected your ability to manage everyday life. Please answer every section and mark only ONE box that applies to you. We realize that you may consider that two of the same statements in any one section relate to you, but please just mark the box that most closely describes your problem.

Pain Intensity

Personal Care (Washing, Dressing, etc.)

Lifting

Reading

Headaches

Concentration

Work

Driving

Sleeping

Recreation

Rate the severity of your pain: 0 (no pain) – 10 (unbearable pain)

Your Name (required)

Your Email (required)

Your Message