Free Pain Quiz - Minimally Invasive Spine

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602-265-4816
(602) 532-7330

602-265-4816
(602) 532-7330

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Pain Screening Quiz

Pain presents itself in many different ways, at different times and in many cases is triggered by specific activities. Minimally Invasive Spine AZ will be happy to answer your questions in conjunction with a personal phone call follow up with one of our doctors. Please answer the questions as accurately as possible.

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Where is your pain?*
- Lumbar (Lower Back)
- Thoracic (Mid Back)
- Cervical (Neck)
- Head
- Shoulder
- Hip
- Knee
- Foot

Have you been diagnosed with any of the following?*
- Herniated/Bulging Disc or Annular Tear
- Degenerative Disc Disease (DDD)
- Spondylosis
- Stenosis
- Sciatica
- Radiculopathy
- Pinched Nerve
- Facet Joint Syndrome
- Bone Spurs/Osteophytes
- Other

How would you describe your pain?*
- Shooting Pain
- Sharp
- Burning
- Cramping
- Throbbing
- Other

Do you have any associated symptoms?*
- Pins
- Needles
- Numbness
- Weakness
- Tingling
- Other

What triggers your pain?*
- Sitting
- Standing
- Walking
- Laying Down
- Bending Forward
- Bending Backward
- Other

What improves or alleviates your pain?*
- Sitting
- Standing
- Walking
- Laying Down
- Bending Forward
- Bending Backward
- Other

What tests have you had?*
- CT Scan
- MRI
- XRay
- Other

What treatments have you had to treat the pain?*
- Chiropractic Treatment
- Physical Therapy
- Acupuncture
- Spinal Injections
- Spine Surgery
- Other

Age
Name*
First Last
Phone*

Email*
Insurance
- Private
- Medicare
- Medicare + Supp
- None
- Auto Accident/Personal Injury
- Work Comp
- Self Pay
Insurance Type
- HMO
- PPO
- POS
- Other
Additional Comments
As doctors, we understand your privacy concerns and will only attempt to contact you if you want our help.

Get In Touch

thankyou@azptc.com

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1301 E McDowell Rd., Suite #100
Phoenix AZ 85006

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4860 E. BASELINE RD., SUITE #103
MESA, AZ 85206

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8805 N. 23RD AVE., SUITE #120
PHOENIX, AZ 85021

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