Evaluation Tool What's your first name? What's your last name? What's your email address? Where do you feel pain? Shoulders Neck Back Severity of pain in the area? Severe Moderate Mild What does the pain feel like? Throbbing Sharp Burning Intermittent Constant Dull Numbness How long have you had the pain? Less than 6 weeks More than 12 weeks More than 6 weeks When is the pain most severe? Morning Afternoon Evening Overnight What have you done to combat the pain? OTC Medication Prescription Medication Massages Brace Ice/Heat Physical Therapy Epidural Other Which of the following practitioners have you seen regarding this issue? Chiropractor Primary Care Doctor Other Medical Specialist Orthopedic Doctor I have not seen another practitioner Submit