Name * First Name Last Name Email * Phone * (###) ### #### What is your age? * <31 years old 31-54 years old >55 years old How long have you had low back pain? * Less than 1 month 1-3 months More than 3 months Does the pain in your back travel anywhere? * My back pain does not travel anywhere Travels to my hip Travels down to my thigh Travels down past my knee My pain is made worse by * Standing Sitting Bending / Lifting from ground Laying down Walking Standing up from chair My pain is improved by Sitting Standing Moving / Walking Laying down Nothing I also experience * Weakness of leg, feet or toes Groin numbness Tingling or numbness of leg, foot or toe Bowel or bladder changes Fever Changes to my gait No additional symptoms How did your pain begin? * Of unknown origin Repetitively Following trauma (slip, fall, auto accident, etc) During a workout Following a workout One of providers will be in touch to review your low back pain report shortly. We look forward to speaking with you about your lower back pain.
