Disc Condition Self-Assessment Questionnaire Form
Complete this brief self-assessment to reflect on your current disc condition symptoms and experiences. Your responses are confidential and for personal use only.
First Name
*
How would you rate your current level of back discomfort?
*
1
2
3
4
5
Which of the following best describes your typical pain pattern?
*
Intermittent pain
Constant pain
Pain with movement only
No pain
Other
Which areas do you experience discomfort? (Select all that apply)
*
Lower back
Neck
Mid-back
Leg(s)
Arm(s)
Other
Please rate the severity of the following symptoms:
*
Rows
None
Mild
Moderate
Severe
Stiffness
1
2
3
4
Numbness or tingling
5
6
7
8
Weakness
9
10
11
12
Reduced mobility
13
14
15
16
How often do you experience symptoms related to your disc condition?
*
Rarely
Occasionally
Frequently
Almost always
Which activities are most affected by your symptoms? (Select all that apply)
Sitting
Standing
Walking
Lifting
Sleeping
Other
Have you previously discussed these symptoms with a healthcare provider?
Yes
No
Is there anything else you'd like to share about your experience?
Submit Self-Assessment
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