1. How long have you had this pain? Less than six months.    Six months to a year.    More than a year.   

2. On a scale of 1-10, with "10" being the worst, how would you rate your pain? 1    2    3    4    5    6    7    8    9    10   

3. Have you seen another doctor for this condition? Yes    No   

4. Have you had physical therapy for this condition? Yes    No   

5. Do you have MRI or x-ray studies of your back/neck? Yes    No   

6. Have you been told you should consider surgery for your condition? Yes    No   

7. Is your pain chronic or does it come and go? Chronic    Comes and Goes   

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