This is how it works:
1. Answer the questions as thoroughly as possible.
2. Provide contact information in order to receive the doctors review.
3. Once the doctor has completed the review we will contact you with your results.
Getting a good understanding of your condition is critical to making the right choice for your care.
Using the pain scale below, please rate the severity of your pain with 1 being the least and 10 being the worst.
Please rate your pain to start.
1-3: Mild Pain, no problem to live with it.
4-6: Moderate Pain, unbearable sometimes.
7-9: Severe Pain, unbearable most of the time.
10: Excruciating Pain, can not live with the pain at all and pain is horrible.
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Using your mouse, click on the body where you are experiencing pain or discomfort.
Click on as many areas as you need to in order to let us know all your areas of concern.
Radiating leg pain through your legs or feet is a common symptom of a spine related problems.
Because your pain is lower back, choose an answer that best describes if pain radiates to your legs.
Select if Pain Radites through your leg(s)
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Radiating arm pain through your arms or hands is a common symptom of a spine related problems.
Because your pain is upper back/neck, choose an answer that best describes if pain radiates to your arms.
Select if Pain Radites through your arm(s)
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Radiating face pain can be a symptom of a rare spinal condition.
Select if Pain Radites through your Face
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Along with radiating face pain, having Multiple Sclerosis most likely points to a very specific spinal condition called Trigeminal Neuralgia.
Select if you have multiple sclerosis.
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Describing your pain accurately can make it easier for your doctor to find the cause of your pain and recommend the right treatment. Please select all of the choices that help best describe your pain.
From the choices below, select those that best describe your pain.
Select type of pain you experience.
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Understanding the origins behind your pain is very important. When did you first notice the pain? Has the pain gotten worse over time?
Pain is normally caused by trauma or degeneration (wear and tear). For example, you can twist your knee playing tennis and feel immediate pain, or you can develop pain in your shoulder from playing tennis for 8 hours a day all summer. One pain is immediate and the other pain develops gradually over time.
Select how your pain started.
Select how your pain started
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Co-ordinating how long you have been in pain alongside the origin of the pain helps the doctor get a clear understanding of how your pain has progressed and how deeply rooted the pain is. Pain that has lasted for years has deep roots and can be approached differently then pain that has only been around for a few days or weeks.
From the choices below, do your best to select the one that best indicates how long you have been in pain for.
Select how long you had pain
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Every pain is different and determining what movements or actions initiate the feeling of pain or make the pain feel worse helps the doctor better understand the cause and source of the pain.
From the choices below, select all of them that either initiate your pain or make your pain worse.
Select activities that trigger pain
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Just as some activities or motions can be harmful, some of them can actually help alleviate your pain and make you more comfortable. This to is important for the doctor to help him better understand the starting point for your relief.
From the choices below, select all of them that either alleviate your pain or make your pain less.
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Some people live with pain for years and never see a doctor. Some people get injured and are at the doctor the next day. It is important to share with the doctor all your previous treatments. Sharing this will help the doctor determine a starting point for your treatment moving forward.
Select all of the treatments listed below that you have already had in the past.
Select activities that alleviate pain
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Sometimes there are other symptoms present with the onset of back or neck pain.
Determining what symptoms are associated with your pain helps the doctor identify the cause of your pain.
Please select any associated pain symptoms.
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If you have already had some medical image testing done such as an XRAY, MRI or CT Scan, the doctor can use those tests to help in his diagnosis of your pain. Sometimes the test can be outdated however and the doctor may or may not require you to get new tests done.
Select all of the medical image tests that you have had done.
Select image tests you have had
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The doctor benefits greatly from having a general outline of your personal stats. Age height and weight all play a significant role in helping to determine factors that may or may not be associated to your pain.
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Thanks for taking the time to fill out the pain evaluation. Once submitted it will be reviewed and once the review is complete we will send you your results. The results will contain likely conditions and recommended next steps.
We can either text them to you or contact you directly by phone.
Select how you want to recieve doctor's feedback
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We just need your basic contact info so we can get your pain evaluation results back to you as soon as the evaluation has been reviewed.
What to Expect Next
1. Once submitted your pain evaluation will be reviewed.
2. Based on the review, some likely conditions will be provided.
3. Based on likely conditions we will provide some recommended next steps
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Go Back 18 / 18 Submit
Your pain evaluation has been submitted to the Doctor for Review.
You will receive a response from the Doctor in less than 24 - 48 hours.
Your submission is received and we will contact you soon
Book an Appointment
Fax : 469/709-1948 Phone: (972)865-4454 Email: email@example.com
13988 Diplomat Drive, Suite 100 Farmers Branch, TX 75234
2700 W Pleasant Run Rd Ste 340, Lancaster, TX 75146
3600 W 7th Street, Suite A Fort Worth, TX 76107
802 W Lampasas Street Ennis, TX 75119
31304 West Texas Ave. Midland, TX 79701
6101 Windhaven Pkwy, Suite 145 Plano, TX 75093
117 Jane Lane, Hillsboro, TX 76645
6407 S Cooper St #117, Arlington, TX 76001
3003 Fannin Street, Houston, TX 77004
I have included with this referral:(INCOMPLETE REFERRAL WILL DELAY THE SCHEDULING PROCESS)
Patient Demographic sheet(that includes insurance information, LOP or Workers Comp)
Treating Doctor's Initial Evalution, Office Visit Notes & Physical Therapy Notes
Diagnostics(MRI's, EMG's, X-Rays, CT's, Discograms, Myelograms )
Thank you we will get back to you soon ...