Low Back Pain Questionnaire

Please take a few minutes to complete this form. This information will be very helpful in establishing a diagnosis and assist in developing a treatment plan for you. This information will be placed into your records and be maintained in strict confidence

How long have you had:

If yes, please list:

This questionnaire has been designed to provide information as to how your back pain has affected your ability to manage in everyday life. Please answer every question by placing a mark in the one option that best describes your condition today. We realize you may feel that 2 of the statements may describe your condition, but please select only one option that most closely describes your current condition

Please submit completed form to ConciergeCare@payerfusion.com