Back Pain Medical Report Form
Please provide details about your back pain experience to assist with your medical assessment.
Full Name
*
First Name
Last Name
Email Address
*
example@example.com
Date of Report
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Location of Back Pain
*
Please Select
Upper Back
Middle Back
Lower Back
Entire Back
Other
Pain Severity (1 = Mild, 10 = Severe)
*
Mild
1
2
3
4
5
6
7
8
9
Severe
10
1 is Mild, 10 is Severe
Duration of Pain
*
Please Select
Less than 1 week
1-4 weeks
1-3 months
More than 3 months
Nature of Pain
*
Sharp
Dull
Burning
Throbbing
Radiating
Other
What makes the pain worse?
Movement
Sitting
Standing
Lifting
Other
What relieves the pain?
Rest
Heat/Ice
Medication
Physical Therapy
Other
Impact on Daily Activities
Additional Comments
Submit Report
Should be Empty: